Provider Demographics
NPI:1760488068
Name:TARASOV, ETHAN A (MD)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:A
Last Name:TARASOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3625 QUAKERBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08619-1207
Mailing Address - Country:US
Mailing Address - Phone:609-689-1600
Mailing Address - Fax:609-689-1200
Practice Address - Street 1:2501 KUSER RD
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NJ
Practice Address - Zip Code:08691-3302
Practice Address - Country:US
Practice Address - Phone:609-585-8800
Practice Address - Fax:609-585-1825
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2012-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA047854002085R0202X
PAMD035415-E2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7345607Medicaid
PA01536103Medicaid
E13229Medicare UPIN
PA695946Medicare PIN
PA01536103Medicaid