Provider Demographics
NPI:1588814131
Name:BURGHER, TARA BLALOCK (DO)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:BLALOCK
Last Name:BURGHER
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 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10620 PARK RD
Practice Address - Street 2:STE 202
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8472
Practice Address - Country:US
Practice Address - Phone:704-667-0920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-19
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2020-00713207Q00000X, 207Q00000X
IAR10399207Q00000X
AL1024A231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologist