Provider Demographics
NPI:1437197027
Name:EASLEY, TARA M (MD)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:M
Last Name:EASLEY
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 1:2411 W BELVEDERE AVE STE 508
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-5232
Mailing Address - Country:US
Mailing Address - Phone:410-601-8383
Mailing Address - Fax:
Practice Address - Street 1:2411 W BELVEDERE AVE STE 508
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-5232
Practice Address - Country:US
Practice Address - Phone:410-601-8383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38496208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64089337Medicaid
KYI-18707Medicare UPIN
KY64089337Medicaid