MEDICARE: DR. BLAKE W TARR O.D.

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
1	152W00000X	Optometrist	2482	TN
2	152WC0802X	Corneal and Contact Management Optometrist	2482	TN
3	152WP0200X	Pediatric Optometrist	2482	TN
4	152WS0006X	Sports Vision Optometrist	2482	TN

General Provider Information

NPI Number	:	1235323759
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BLAKE W TARR O.D.

Provider Business Mailing Address
First Line	:	PO BOX 766
Second Line	:
City	:	JEFFERSON CITY
State	:	TN
Zip	:	37760-0766
Country	:	US
Telephone Number	:	865-475-6565
Fax Number	:

Provider Business Practice Location Address
First Line	:	555 W HIGHWAY 11E
Second Line	:
City	:	NEW MARKET
State	:	TN
Zip	:	37820-4305
Country	:	US
Telephone Number	:	865-475-6565
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/28/2007
Last Update Date	:	01/27/2023

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