Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207T00000X | Neurosurgeon | H4230 | TX |
NPI | 1104824671 |
---|---|
Provider Name | Tamerla Dawn Chavis |
First Address | Beaumont, TX 77702 |
Second Address | Beaumont, TX 77702 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/07/2005 |
Last Update Date | 25/06/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
030803301 | (05) | TX |
140066844 | MEDICARE RR (01) | |
G21519 | (02) |