Provider Demographics
NPI:1376812008
Name:TA, DONALD (MD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:
Last Name:TA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 ALEX LN
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-2952
Mailing Address - Country:US
Mailing Address - Phone:304-734-2040
Mailing Address - Fax:304-734-2047
Practice Address - Street 1:107 KOONTZ AVE
Practice Address - Street 2:
Practice Address - City:CLENDENIN
Practice Address - State:WV
Practice Address - Zip Code:25045-9578
Practice Address - Country:US
Practice Address - Phone:304-548-7272
Practice Address - Fax:304-548-7149
Is Sole Proprietor?:No
Enumeration Date:2011-12-27
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV27153208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics