Provider Demographics
NPI:1437683687
Name:CHOUAKE, TARA (MD)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:CHOUAKE
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 1:291 BROADWAY RM 710
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10007-1928
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:291 BROADWAY RM 710
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10007-1928
Practice Address - Country:US
Practice Address - Phone:917-719-6156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-14
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY2995122084P0804X
NJ25MA114602002084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program