MEDICARE: DR. TARA BETH WILSON M.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	208600000X	Surgery Physician	31333	OK
2	208600000X	Surgery Physician	ME162877	FL

General Provider Information

NPI Number	:	1922176429
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TARA BETH WILSON M.D.

Provider Business Mailing Address
First Line	:	1890 LPGA BLVD STE 250
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32117-7131
Country	:	US
Telephone Number	:	386-274-0250
Fax Number	:	386-274-0269

Provider Business Practice Location Address
First Line	:	501 LIVE OAK ST
Second Line	:
City	:	NEW SMYRNA BEACH
State	:	FL
Zip	:	32168-7300
Country	:	US
Telephone Number	:	386-274-0250
Fax Number	:

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

Provider Enumeration Date	:	12/01/2006
Last Update Date	:	08/16/2023

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