Provider Demographics
NPI:1710913900
Name:GUSTILO, TARA L (MD MPH)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:GUSTILO
Suffix:
Gender:F
Credentials:MD MPH
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:L
Other - Last Name:GUSTILO-ASHBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD MPH
Mailing Address - Street 1:434 4TH ST STE 305
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37821-3735
Mailing Address - Country:US
Mailing Address - Phone:423-415-3330
Mailing Address - Fax:423-613-1173
Practice Address - Street 1:434 4TH ST STE 305
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:TN
Practice Address - Zip Code:37821-3735
Practice Address - Country:US
Practice Address - Phone:423-415-3330
Practice Address - Fax:423-613-1173
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35084663207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2557782Medicaid
OH2557782Medicaid