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NPI Code Detail

MEDICARE: DR. STACY TAMARA TARRADATH MD

MEDICARE: DR. STACY TAMARA TARRADATH MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine Physician278459 DUPNY
2207Q00000XFamily Medicine PhysicianAAA4688CA

General Provider Information

NPI Number : 1053569095
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. STACY TAMARA TARRADATH MD
Provider Business Mailing Address
First Line : 3175 23RD ST
Second Line :
City : ASTORIA
State : NY
Zip : 11106-4134
Country : US
Telephone Number : 718-956-2200
Fax Number :
Provider Business Practice Location Address
First Line : 8501 WILSHIRE BLVD STE 150
Second Line :
City : BEVERLY HILLS
State : CA
Zip : 90211-3148
Country : US
Telephone Number : 310-248-7000
Fax Number : 310-248-7033
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/03/2008
Last Update Date : 02/24/2020

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