1639193568 NPI number — TARA L STOCK DO

Table of content: TARA L STOCK DO (NPI 1639193568)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639193568 NPI number — TARA L STOCK DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STOCK
Provider First Name:
TARA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1639193568
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1397 MEDICAL PARK BLVD
Provider Second Line Business Mailing Address:
SUITE 460
Provider Business Mailing Address City Name:
WELLINGTON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33414-3186
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-791-4434
Provider Business Mailing Address Fax Number:
561-795-0464

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1395 S STATE ROAD 7 STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WELLINGTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33414-9326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-791-4434
Provider Business Practice Location Address Fax Number:
561-795-0464
Provider Enumeration Date:
07/26/2006

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: 207Q00000X , with the licence number:  OS9521 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 102820500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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