Provider Demographics
NPI:1083613541
Name:ROSE, TARA KERN (OD)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:KERN
Last Name:ROSE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:TARA
Other - Middle Name:RUTH
Other - Last Name:KERN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:121 GOLFVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MC MURRAY
Mailing Address - State:PA
Mailing Address - Zip Code:15317-5327
Mailing Address - Country:US
Mailing Address - Phone:724-969-6936
Mailing Address - Fax:724-969-6936
Practice Address - Street 1:450 CENTURY III MALL
Practice Address - Street 2:
Practice Address - City:WEST MIFFLIN
Practice Address - State:PA
Practice Address - Zip Code:15122
Practice Address - Country:US
Practice Address - Phone:412-655-1988
Practice Address - Fax:412-653-6460
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017809350002Medicaid
U80795Medicare UPIN