Provider Demographics
NPI:1891895777
Name:MERRITT, TARA ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:ANN
Last Name:MERRITT
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:1181 LANGFORD DRIVE
Mailing Address - Street 2:BLDG 200 SUITE 101
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677
Mailing Address - Country:US
Mailing Address - Phone:706-850-8750
Mailing Address - Fax:706-850-8760
Practice Address - Street 1:1181 LANGFORD DR
Practice Address - Street 2:BLDG 200 SUITE 101
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-7242
Practice Address - Country:US
Practice Address - Phone:706-850-8750
Practice Address - Fax:706-850-8760
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2015-10-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA58543207R00000X, 208000000X, 2080S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA489449582AMedicaid
GA489449582AMedicaid
GA11SCGPWMedicare PIN