Provider Demographics
NPI:1689221210
Name:MULLEN, TARA K
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:K
Last Name:MULLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:427 BEACH 122ND ST
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11694-1826
Mailing Address - Country:US
Mailing Address - Phone:347-752-8244
Mailing Address - Fax:
Practice Address - Street 1:525 E 68TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-4870
Practice Address - Country:US
Practice Address - Phone:212-746-5026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF344194-1207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYMM5404152OtherDEA REGISTRATION NUMBER