Provider Demographics
NPI:1902859069
Name:TAHARA, ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:TAHARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:900 CHESTNUT STREET EXT
Mailing Address - Street 2:STE A
Mailing Address - City:BRADFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16701-2298
Mailing Address - Country:US
Mailing Address - Phone:814-368-8490
Mailing Address - Fax:814-368-8490
Practice Address - Street 1:900 CHESTNUT STREET EXT
Practice Address - Street 2:SUITE A
Practice Address - City:BRADFORD
Practice Address - State:PA
Practice Address - Zip Code:16701-2298
Practice Address - Country:US
Practice Address - Phone:814-368-8490
Practice Address - Fax:814-368-8041
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD419351L208600000X
PAMD4193512086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019079900001Medicaid
PA0019079900001Medicaid
PA060132QUNMedicare ID - Type Unspecified