MEDICARE: TARA MARIE FORMISANO DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	1015917	MA
2	207V00000X	Obstetrics & Gynecology Physician	94477	SC

General Provider Information

NPI Number	:	1548720121
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA MARIE FORMISANO DO

Provider Business Mailing Address
First Line	:	721 OKATIE HWY
Second Line	:
City	:	OKATIE
State	:	SC
Zip	:	29909-3963
Country	:	US
Telephone Number	:	843-987-7400
Fax Number	:

Provider Business Practice Location Address
First Line	:	1264 RIBAUT RD
Second Line	:
City	:	BEAUFORT
State	:	SC
Zip	:	29902-6123
Country	:	US
Telephone Number	:	843-986-0900
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/21/2019
Last Update Date	:	06/18/2026

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Directions to “ TARA MARIE FORMISANO DO” Practice Location

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