1336146497 NPI number — DR. TARA LYNN SVATOS O.D.

Table of content: DR. TARA LYNN SVATOS O.D. (NPI 1336146497)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336146497 NPI number — DR. TARA LYNN SVATOS O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SVATOS
Provider First Name:
TARA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336146497
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 549
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WABASH
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46992-0549
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-569-9550
Provider Business Mailing Address Fax Number:
260-569-0760

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13197 STATE ROAD 23
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANGER
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46530
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-247-1500
Provider Business Practice Location Address Fax Number:
574-247-1505
Provider Enumeration Date:
07/05/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  18002580 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 410049816 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000277906 . This is a "ANTHEM BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: P01598940 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 4777440001 . This is a "DME MAC" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100093180 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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