Basic Information
Provider Information | |||||||||
NPI: | 1750568242 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TAVIS | ||||||||
FirstName: | JEFFREY | ||||||||
MiddleName: | HAN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 203 W 6TH ST | ||||||||
Address2: |   | ||||||||
City: | CORONA | ||||||||
State: | CA | ||||||||
PostalCode: | 928823302 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9513568500 | ||||||||
FaxNumber: | 9513568828 | ||||||||
Practice Location | |||||||||
Address1: | 12900 PARK PLAZA DR | ||||||||
Address2: | STE 150, MS 7110 | ||||||||
City: | CERRITOS | ||||||||
State: | CA | ||||||||
PostalCode: | 907039329 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5627414470 | ||||||||
FaxNumber: | 5627414479 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/27/2008 | ||||||||
LastUpdateDate: | 04/17/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A102252 | CA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.