Provider Demographics
NPI:1366409906
Name:DARA, TANVIR M (MD)
Entity type:Individual
Prefix:
First Name:TANVIR
Middle Name:M
Last Name:DARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4475 WEST VILLAGE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-2634
Mailing Address - Country:US
Mailing Address - Phone:561-998-8889
Mailing Address - Fax:
Practice Address - Street 1:15 S MAIN ST STE 270
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-6629
Practice Address - Country:US
Practice Address - Phone:716-489-3144
Practice Address - Fax:716-489-3152
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY197036207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01613065Medicaid
NYF35077Medicare UPIN
NY01613065Medicaid