Healthcare Provider Details

I. General information

NPI: 1104034248
Provider Name (Legal Business Name): TARA MITCHELL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 12/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2370 GAUSE BOULEVARD
SLIDELL LA
70464
US

IV. Provider business mailing address

1514 JEFFERSON HWY
NEW ORLEANS LA
70121
US

V. Phone/Fax

Practice location:
  • Phone: 985-639-3755
  • Fax:
Mailing address:
  • Phone: 504-842-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number27112
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD.202215
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: