Provider Demographics
NPI:1386826519
Name:TAGALA, PRAXIDIO H (MD)
Entity Type:Individual
Prefix:
First Name:PRAXIDIO
Middle Name:H
Last Name:TAGALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PRAXIDIO
Other - Middle Name:H
Other - Last Name:TAGALA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:615 THOMPSON ST
Mailing Address - Street 2:
Mailing Address - City:CLEARFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:16830-1227
Mailing Address - Country:US
Mailing Address - Phone:814-765-4369
Mailing Address - Fax:814-768-7890
Practice Address - Street 1:615 THOMPSON ST
Practice Address - Street 2:
Practice Address - City:CLEARFIELD
Practice Address - State:PA
Practice Address - Zip Code:16830-1227
Practice Address - Country:US
Practice Address - Phone:814-765-4369
Practice Address - Fax:814-768-7890
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-29
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038410-L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0861458Medicaid
086364Medicare UPIN
PA0861458Medicaid