Healthcare Provider Details

I. General information

NPI: 1508096512
Provider Name (Legal Business Name): TARA SMITH FESTA O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2009
Last Update Date: 11/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3290 DAUPHIN ST. SUITE 401
MOBILE AL
36606-4053
US

IV. Provider business mailing address

250 STATE FARM PKWY
BIRMINGHAM AL
35209-7181
US

V. Phone/Fax

Practice location:
  • Phone: 251-471-3309
  • Fax: 251-471-5046
Mailing address:
  • Phone: 205-943-4650
  • Fax: 205-943-4688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2009020664
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberSC26TA845
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: