Provider Demographics
NPI:1255310298
Name:BROADWATER, TARA L (MD)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:L
Last Name:BROADWATER
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 1:898 WESCOTT TRL APT 311
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-2272
Mailing Address - Country:US
Mailing Address - Phone:507-304-1899
Mailing Address - Fax:
Practice Address - Street 1:898 WESCOTT TRL APT 311
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-2272
Practice Address - Country:US
Practice Address - Phone:507-304-1899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-10
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN40655207Q00000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN388R8BUOtherBCBS
IA0573816OtherMEDICAID
MNNA2951032151OtherPREFFERED ONE
MNHP36174OtherHEALTH PARTNERS
MN1965380OtherAMERICAS PPO
MN124673OtherUCARE
41084933956001C212OtherCHAMPUS
MN526011600Medicaid
P00138242OtherRR MEDICARE
MNNA2951032151OtherPREFFERED ONE
MNHP36174OtherHEALTH PARTNERS