Healthcare Provider Details

I. General information

NPI: 1780643684
Provider Name (Legal Business Name): NINA MITHI TAGGART MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 05/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 E BROAD ST
HAZLETON PA
18201-5622
US

IV. Provider business mailing address

703 RUTTER AVE
KINGSTON PA
18704-4801
US

V. Phone/Fax

Practice location:
  • Phone: 570-455-3391
  • Fax: 570-455-9150
Mailing address:
  • Phone: 570-288-7405
  • Fax: 570-288-7406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD047373L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier001432771
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: