Healthcare Provider Details

I. General information

NPI: 1073681474
Provider Name (Legal Business Name): TARA LYNN DIMINO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2605 KEISER BLVD
WYOMISSING PA
19610-3338
US

IV. Provider business mailing address

2605 KEISER BLVD
WYOMISSING PA
19610-3338
US

V. Phone/Fax

Practice location:
  • Phone: 610-685-8500
  • Fax: 610-685-4833
Mailing address:
  • Phone: 610-685-8500
  • Fax: 610-685-4833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD419525
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: