Provider Demographics
NPI:1609919604
Name:THIEL, TARA A (OD)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:A
Last Name:THIEL
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 1:2031 8TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33704-3246
Mailing Address - Country:US
Mailing Address - Phone:727-804-4632
Mailing Address - Fax:
Practice Address - Street 1:8102 CITRUS PARK DR
Practice Address - Street 2:JC PENNEY OPTICAL
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33625
Practice Address - Country:US
Practice Address - Phone:813-926-6288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3689152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist