Provider Demographics
NPI:1780665117
Name:JOSEPH, TARA TERESA (MD)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:TERESA
Last Name:JOSEPH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:TARA
Other - Middle Name:TERESA
Other - Last Name:JACOB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:16124 ORCHARD GROVE RD
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20878-2264
Mailing Address - Country:US
Mailing Address - Phone:301-216-0552
Mailing Address - Fax:
Practice Address - Street 1:933 RUSSELL AVE
Practice Address - Street 2:SUITE D
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20879-3290
Practice Address - Country:US
Practice Address - Phone:301-760-4068
Practice Address - Fax:301-841-7483
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-11
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00501832084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG34676Medicare UPIN