Healthcare Provider Details

I. General information

NPI: 1841448925
Provider Name (Legal Business Name): TARA SUSANNE PIETROBONO D.P.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2008
Last Update Date: 06/13/2022
Certification Date: 06/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CREEKVIEW CT STE A
GREENVILLE SC
29615-4839
US

IV. Provider business mailing address

1 CREEKVIEW CT
GREENVILLE SC
29615-4839
US

V. Phone/Fax

Practice location:
  • Phone: 864-252-4889
  • Fax: 864-252-4254
Mailing address:
  • Phone: 864-252-4889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number577
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHAS0534
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: