Provider Demographics
NPI:1124016118
Name:PELLETIER, TARA KAY (DO)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:KAY
Last Name:PELLETIER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 FODEN ROAD WEST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106
Mailing Address - Country:US
Mailing Address - Phone:207-828-0361
Mailing Address - Fax:207-874-1483
Practice Address - Street 1:100 FODEN ROAD EAST
Practice Address - Street 2:SUITE 201
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106
Practice Address - Country:US
Practice Address - Phone:207-874-1489
Practice Address - Fax:207-523-8590
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA224963207Q00000X
ME1957207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEME214001Medicare PIN
MEME2140Medicare PIN
MAA38736Medicare ID - Type Unspecified
MESX4581Medicare PIN