Provider Demographics
NPI:1043414105
Name:GRIMALDI, TARA JILL (MD)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:JILL
Last Name:GRIMALDI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:TARA
Other - Middle Name:JILL
Other - Last Name:MINARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:20930 W 151ST
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66061
Mailing Address - Country:US
Mailing Address - Phone:913-782-2525
Mailing Address - Fax:913-782-9307
Practice Address - Street 1:20930 W 151ST
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061
Practice Address - Country:US
Practice Address - Phone:913-782-2525
Practice Address - Fax:913-782-9307
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-32569208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200441540AMedicaid
KS033D00069Medicare PIN