Provider Demographics
NPI:1578238259
Name:ELAM, TARA MARSHALL (OD)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:MARSHALL
Last Name:ELAM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 LIND ST
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37110-1924
Mailing Address - Country:US
Mailing Address - Phone:731-446-0929
Mailing Address - Fax:
Practice Address - Street 1:312 N CHANCERY ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:TN
Practice Address - Zip Code:37110-2048
Practice Address - Country:US
Practice Address - Phone:931-473-7844
Practice Address - Fax:931-473-6840
Is Sole Proprietor?:No
Enumeration Date:2021-08-13
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD0000003685152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist