Provider Demographics
NPI:1124017009
Name:OSTROM, TARA MARIA (MD)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:MARIA
Last Name:OSTROM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:623-869-5000
Mailing Address - Fax:623-869-0927
Practice Address - Street 1:20040 N 19TH AVE
Practice Address - Street 2:SUITE A
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-4255
Practice Address - Country:US
Practice Address - Phone:623-869-5000
Practice Address - Fax:623-869-0927
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ26889207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ565492Medicaid
70827Medicare PIN
AZZ197522Medicare PIN
H37595Medicare UPIN