Healthcare Provider Details

I. General information

NPI: 1154380129
Provider Name (Legal Business Name): TARA J CAUDILL-DEATON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 03/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 W 12 MILE RD
MADISON HEIGHTS MI
48071-4439
US

IV. Provider business mailing address

1200 W 12 MILE ROAD
MADISON HEIGHTS MI
48071-6712
US

V. Phone/Fax

Practice location:
  • Phone: 248-543-0600
  • Fax:
Mailing address:
  • Phone: 248-543-0600
  • Fax: 248-543-0562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301080294
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: