Provider Demographics
NPI:1043415961
Name:SEERY, TARA E
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:E
Last Name:SEERY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16105 SAND CANYON AVE STE 230
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-3780
Mailing Address - Country:US
Mailing Address - Phone:949-764-5347
Mailing Address - Fax:
Practice Address - Street 1:16105 SAND CANYON AVE STE 230
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3780
Practice Address - Country:US
Practice Address - Phone:949-764-5347
Practice Address - Fax:949-557-0221
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036118723207RH0003X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036118723Medicaid
ILR02637Medicare PIN
IL036118723Medicaid
ILR02638Medicare PIN
ILR02639Medicare PIN