Provider Demographics
NPI:1164683835
Name:FEDERLY, TARA J (MD)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:J
Last Name:FEDERLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:J
Other - Last Name:BLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6800 LAKE DR STE 260
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-2504
Mailing Address - Country:US
Mailing Address - Phone:515-630-5022
Mailing Address - Fax:515-630-5026
Practice Address - Street 1:6800 LAKE DR STE 260
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-2504
Practice Address - Country:US
Practice Address - Phone:515-630-5022
Practice Address - Fax:515-630-5026
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-8408208000000X
IA39579207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No208000000XAllopathic & Osteopathic PhysiciansPediatrics