Provider Demographics
NPI:1235156837
Name:VIECHNICKI, TARA M (MD)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:M
Last Name:VIECHNICKI
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 1:477 N EL CAMINO REAL
Mailing Address - Street 2:STE C202
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-1332
Mailing Address - Country:US
Mailing Address - Phone:760-631-3500
Mailing Address - Fax:
Practice Address - Street 1:477 N EL CAMINO REAL STE C202
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-1332
Practice Address - Country:US
Practice Address - Phone:760-631-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101243689207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1235156837Medicaid
017588S05Medicare PIN
H95299Medicare UPIN