MEDICARE: TARA NAOMI NICOLETTE DO

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	207RI0200X	Infectious Disease Physician	36193	SC
2	207RI0200X	Infectious Disease Physician	95410	GA
3	207RI0200X	Infectious Disease Physician	22008	NH
4	207R00000X	Internal Medicine Physician	0116023970	VA
5	207RI0200X	Infectious Disease Physician	02005888A	IN
6	207RI0200X	Infectious Disease Physician	DO2022-0140	NM

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	SCM1003365	OTHER	SC	MEDICARE PIN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942568795
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA NAOMI NICOLETTE DO

Provider Business Mailing Address
First Line	:	PO BOX 743070
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-3070
Country	:	US
Telephone Number	:	864-560-4304
Fax Number	:	864-560-4413

Provider Business Practice Location Address
First Line	:	101 E WOOD ST
Second Line	:
City	:	SPARTANBURG
State	:	SC
Zip	:	29303-3040
Country	:	US
Telephone Number	:	864-560-6806
Fax Number	:	864-560-7329

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

Provider Enumeration Date	:	04/30/2012
Last Update Date	:	01/20/2026

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Directions to “ TARA NAOMI NICOLETTE DO” Practice Location

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