Provider Demographics
NPI:1609225499
Name:TALLAH, CLARISSE (MD)
Entity Type:Individual
Prefix:DR
First Name:CLARISSE
Middle Name:
Last Name:TALLAH
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 1:525 BRANSON LANDING BLVD STE 508
Mailing Address - Street 2:
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-2131
Mailing Address - Country:US
Mailing Address - Phone:417-335-7527
Mailing Address - Fax:417-335-7544
Practice Address - Street 1:525 BRANSON LANDING BLVD STE 508
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-2131
Practice Address - Country:US
Practice Address - Phone:417-335-7540
Practice Address - Fax:417-335-7544
Is Sole Proprietor?:No
Enumeration Date:2016-06-13
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021030592207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200101118Medicaid