Provider Demographics
NPI:1578660528
Name:LATHROP, TARA D (MD)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:D
Last Name:LATHROP
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 1:700 CHIEF EDDIE HOFFMAN HWY
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:AK
Mailing Address - Zip Code:99559
Mailing Address - Country:US
Mailing Address - Phone:907-545-9030
Mailing Address - Fax:
Practice Address - Street 1:230 E. MARYDALE AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-2949
Practice Address - Country:US
Practice Address - Phone:907-262-3119
Practice Address - Fax:907-260-7320
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60157114207P00000X
AK3076207Q00000X
AK6010207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKRH177FQMedicaid
AKMD2357Medicaid
AKMD2357Medicaid
AKRH177FQMedicaid