Healthcare Provider Details

I. General information

NPI: 1235790130
Provider Name (Legal Business Name): THERESA THARAKAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2019
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 NW 14TH ST FL 5
MIAMI FL
33136-2107
US

IV. Provider business mailing address

660 SOUTH EUCLID AVE OTOLARYNGOLOGY HEAD AND NECK SURGERY
ST LOUIS MO
63110
US

V. Phone/Fax

Practice location:
  • Phone: 305-243-1349
  • Fax:
Mailing address:
  • Phone: 314-362-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number2019020210
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberME181690
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: