Provider Demographics
NPI:1235420514
Name:BZDOK, TARA (RD, CSR, LD)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:BZDOK
Suffix:
Gender:F
Credentials:RD, CSR, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2713 BLAKE ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78748-3951
Mailing Address - Country:US
Mailing Address - Phone:512-608-4054
Mailing Address - Fax:512-852-6691
Practice Address - Street 1:400 HOSPITAL DR
Practice Address - Street 2:STE 106
Practice Address - City:CORSICANA
Practice Address - State:TX
Practice Address - Zip Code:75110-2489
Practice Address - Country:US
Practice Address - Phone:512-809-3689
Practice Address - Fax:512-367-5692
Is Sole Proprietor?:No
Enumeration Date:2011-04-21
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
TXDT81976133V00000X
1006838133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX312032OtherMEDICARE PTAN