Provider Demographics
NPI:1649243445
Name:DALL, TARA L (MD)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:DALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:601 GENESEE ST UNIT 303
Mailing Address - Street 2:
Mailing Address - City:DELAFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53018-1410
Mailing Address - Country:US
Mailing Address - Phone:888-498-5296
Mailing Address - Fax:888-495-8194
Practice Address - Street 1:601 GENESEE ST UNIT 303
Practice Address - Street 2:
Practice Address - City:DELAFIELD
Practice Address - State:WI
Practice Address - Zip Code:53018-1410
Practice Address - Country:US
Practice Address - Phone:888-498-5296
Practice Address - Fax:888-495-8194
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2022-09-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101252696207Q00000X
WI41339207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIH35783Medicare UPIN
WI32610400Medicaid