Provider Demographics
NPI:1033152418
Name:RAY, TARA FAWN (DO)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:FAWN
Last Name:RAY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:TARA
Other - Middle Name:FAWN
Other - Last Name:ALFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 9189
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-0189
Mailing Address - Country:US
Mailing Address - Phone:304-767-7960
Mailing Address - Fax:304-767-7969
Practice Address - Street 1:400 DIVISION ST
Practice Address - Street 2:SUITE 3
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1459
Practice Address - Country:US
Practice Address - Phone:304-767-7960
Practice Address - Fax:304-767-7969
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21172084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810002665Medicaid
WV208724900OtherTAX IDENTIFICATION
OH2616995OtherMEDICAID
I32136Medicare UPIN
RA4161051Medicare ID - Type Unspecified