Provider Demographics
NPI:1821031519
Name:MOUTSATSON, TAMARA J (DO)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:J
Last Name:MOUTSATSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2853 HEALTH PKWY STE A
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-9375
Mailing Address - Country:US
Mailing Address - Phone:989-779-5222
Mailing Address - Fax:989-953-5153
Practice Address - Street 1:2853 HEALTH PKWY STE A
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-9375
Practice Address - Country:US
Practice Address - Phone:989-779-5222
Practice Address - Fax:989-953-5153
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014853207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4799420Medicaid
MI4799420Medicaid