Provider Demographics
NPI:1841410479
Name:TARAS, ANGIE ROSANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:ANGIE
Middle Name:ROSANNE
Last Name:TARAS
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 1:2760 WYNFIELD LN
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-3352
Mailing Address - Country:US
Mailing Address - Phone:312-659-8005
Mailing Address - Fax:
Practice Address - Street 1:2350 RAVINE WAY
Practice Address - Street 2:400
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-7621
Practice Address - Country:US
Practice Address - Phone:312-715-7552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI55873-20208D00000X, 208600000X
PAMD458999208600000X
TXR1660208600000X
CA149480208600000X
MI4301111045208600000X
NE29826208600000X
IL036129138208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201083390AMedicaid