1396052163 NPI number — DR. TARRA JUSTINE WINCHELL O.D.

Table of content: DR. TARRA JUSTINE WINCHELL O.D. (NPI 1396052163)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396052163 NPI number — DR. TARRA JUSTINE WINCHELL O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WINCHELL
Provider First Name:
TARRA
Provider Middle Name:
JUSTINE
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:
1396052163
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
62 GENERAL MAXWELL CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19702-2452
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-668-8750
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19 HAINES ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19711-4610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-239-1933
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/01/2010

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:  I3-0001348 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: OEG002416 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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