Provider Demographics
NPI:1336101229
Name:STURDIVANT, TARA (MD)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:
Last Name:STURDIVANT
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 1:1522 CHEROKEE TRL
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-2205
Mailing Address - Country:US
Mailing Address - Phone:865-546-9221
Mailing Address - Fax:
Practice Address - Street 1:1522 CHEROKEE TRL
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-2205
Practice Address - Country:US
Practice Address - Phone:865-546-9221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN24940207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNE62203Medicare UPIN