Provider Demographics
NPI:1235144023
Name:RUSOFF, TARA M (OD)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:M
Last Name:RUSOFF
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:TARA
Other - Middle Name:M
Other - Last Name:JOHNSON-RUSOFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:3434 E LAKE RD STE 3
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34685-2403
Mailing Address - Country:US
Mailing Address - Phone:727-781-7922
Mailing Address - Fax:727-789-9859
Practice Address - Street 1:3434 E LAKE RD STE 3
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34685-2403
Practice Address - Country:US
Practice Address - Phone:727-781-7922
Practice Address - Fax:727-789-9859
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3810152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAD140ZMedicare PIN
U79045Medicare UPIN