Healthcare Provider Details

I. General information

NPI: 1770532293
Provider Name (Legal Business Name): TARA LYN CUDA DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 04/15/2021
Certification Date: 04/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2230 SOUTH BROAD ST
PHILADELPHIA PA
19145
US

IV. Provider business mailing address

2230 SOUTH BROAD ST
PHILADELPHIA PA
19145
US

V. Phone/Fax

Practice location:
  • Phone: 215-334-3869
  • Fax: 215-755-3300
Mailing address:
  • Phone: 215-755-2800
  • Fax: 215-755-3300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number05008552L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: