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General NPI Number Information
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NPI Number | 1548720121
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Entity Type | Individual
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Provider Name | TARA MARIE FORMISANO DO
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Gender | Female
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Dates
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Enumeration Date | 03/21/2019
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Last Update Date | 09/04/2025
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Provider Practice Location Address
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Address Line | 1264 RIBAUT RD
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City | BEAUFORT
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State | SC
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Zip | 29902-6123
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Country | US
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Telephone | 843-987-7400
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Fax |
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Provider Business Mailing Address
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Address Line | 721 OKATIE HWY
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City | OKATIE
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State | SC
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Zip | 29909-3963
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Country | US
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Telephone | 843-987-7400
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | 94477
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 1015917
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License Number State | MA
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