Healthcare Provider Details

I. General information

NPI: 1558756866
Provider Name (Legal Business Name): TARA D MARCZAK D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2015
Last Update Date: 06/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 CONCORD AVE STE 1200
CAMBRIDGE MA
02138-1055
US

IV. Provider business mailing address

725 CONCORD AVE STE 1200
CAMBRIDGE MA
02138-1055
US

V. Phone/Fax

Practice location:
  • Phone: 617-354-5452
  • Fax: 617-354-0458
Mailing address:
  • Phone: 617-354-5452
  • Fax: 617-354-0458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: