Healthcare Provider Details

I. General information

NPI: 1821192006
Provider Name (Legal Business Name): TARA MARIE THERESE SHERIDAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2006
Last Update Date: 12/19/2023
Certification Date: 12/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAL MEDICAL CENTER SAN DIEGO 34800 BOB WILSON DRIVE
SAN DIEGO CA
92134-5000
US

IV. Provider business mailing address

13352 GRANITE CREEK RD
SAN DIEGO CA
92128-4072
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-8943
  • Fax: 619-532-8945
Mailing address:
  • Phone: 619-876-6463
  • Fax: 619-532-8945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA94216
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberA94216
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: