Provider Demographics
NPI:1609008218
Name:STOCK, TARA LYNN (DPM)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:LYNN
Last Name:STOCK
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:LYNN
Other - Last Name:VANSTRANDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:641 W 9 MILE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-1779
Mailing Address - Country:US
Mailing Address - Phone:248-548-7363
Mailing Address - Fax:248-548-5304
Practice Address - Street 1:641 W 9 MILE RD
Practice Address - Street 2:SUITE A
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-1779
Practice Address - Country:US
Practice Address - Phone:248-548-7363
Practice Address - Fax:248-548-5304
Is Sole Proprietor?:No
Enumeration Date:2009-08-14
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002295213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1609008218Medicaid
MIF36430012Medicare PIN
MIF36196009Medicare PIN