Provider Demographics
NPI:1821495581
Name:BROCCOLO, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:BROCCOLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1628 GLENDOWAN TER
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580-8571
Mailing Address - Country:US
Mailing Address - Phone:585-520-1783
Mailing Address - Fax:
Practice Address - Street 1:2111 HUDSON AVE
Practice Address - Street 2:
Practice Address - City:IRONDEQUOIT
Practice Address - State:NY
Practice Address - Zip Code:14617-4346
Practice Address - Country:US
Practice Address - Phone:585-520-1783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-24
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY649366951174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist