Provider Demographics
NPI:1518060375
Name:TATAR, MARY E (PT)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:E
Last Name:TATAR
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:E
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT
Mailing Address - Street 1:156 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-1229
Mailing Address - Country:US
Mailing Address - Phone:585-395-6093
Mailing Address - Fax:585-395-6035
Practice Address - Street 1:156 WEST AVE
Practice Address - Street 2:
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420-1229
Practice Address - Country:US
Practice Address - Phone:585-395-6093
Practice Address - Fax:585-395-6035
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0284601225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00355344Medicaid
NY11616502OtherCAQH
NY00355344Medicaid