Provider Demographics
NPI:1073728051
Name:MOSTOFI, TARA (PAC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:MOSTOFI
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4327 GOLDEN CENTER DR
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-6260
Mailing Address - Country:US
Mailing Address - Phone:530-621-7700
Mailing Address - Fax:530-621-7707
Practice Address - Street 1:4327 GOLDEN CENTER DR
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-6260
Practice Address - Country:US
Practice Address - Phone:530-621-7700
Practice Address - Fax:530-621-7707
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17957207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine