Provider Demographics
NPI:1225275837
Name:FUSSELL, TARA LYNETTE (DPM)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LYNETTE
Last Name:FUSSELL
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:661 E ALTAMONTE DR STE 210
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-5102
Mailing Address - Country:US
Mailing Address - Phone:407-339-7759
Mailing Address - Fax:407-830-0024
Practice Address - Street 1:661 E ALTAMONTE DR STE 210
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-5102
Practice Address - Country:US
Practice Address - Phone:407-339-7759
Practice Address - Fax:407-830-0024
Is Sole Proprietor?:No
Enumeration Date:2009-01-20
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO 3488213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003708200Medicaid
FLFD851ZMedicare PIN