Provider Demographics
NPI:1467565267
Name:MALLETT, TARA S (DO)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:S
Last Name:MALLETT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1007
Mailing Address - Street 2:
Mailing Address - City:LUCEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39452-1007
Mailing Address - Country:US
Mailing Address - Phone:601-947-8181
Mailing Address - Fax:601-947-4411
Practice Address - Street 1:92 W. RATLIFF STREET
Practice Address - Street 2:
Practice Address - City:LUCEDALE
Practice Address - State:MS
Practice Address - Zip Code:39452-6537
Practice Address - Country:US
Practice Address - Phone:601-947-8181
Practice Address - Fax:601-947-4411
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13329208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0112990Medicaid
MS0112990Medicaid
080262738Medicare ID - Type Unspecified