Provider Demographics
NPI:1720379746
Name:TAGUE, LAUREN (MD)
Entity Type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:
Last Name:TAGUE
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 1:725 IRVING AVE STE 804
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1682
Mailing Address - Country:US
Mailing Address - Phone:315-214-7700
Mailing Address - Fax:
Practice Address - Street 1:725 IRVING AVE STE 804
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1682
Practice Address - Country:US
Practice Address - Phone:315-214-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-25
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT390200000X
NY2933282080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program