Provider Demographics
NPI:1548207731
Name:DEAVER, TARA YVETTE (DPM)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:YVETTE
Last Name:DEAVER
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 W 5TH ST
Mailing Address - Street 2:TTUHSC DEPARTMENT OF FAMILY MEDICINE
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79763-4206
Mailing Address - Country:US
Mailing Address - Phone:432-703-5200
Mailing Address - Fax:432-335-5316
Practice Address - Street 1:701 W 5TH ST
Practice Address - Street 2:TTUHSC DEPARTMENT OF FAMILY MEDICINE
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79763-4206
Practice Address - Country:US
Practice Address - Phone:432-703-5200
Practice Address - Fax:432-335-5316
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1425213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX041798202Medicaid
TXU76582Medicare UPIN
TX041798202Medicaid