Provider Demographics
NPI:1922176429
Name:WILSON, TARA BETH (MD)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:BETH
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:BETH
Other - Last Name:HIGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1890 LPGA BLVD STE 250
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-7131
Mailing Address - Country:US
Mailing Address - Phone:386-274-0250
Mailing Address - Fax:386-274-0269
Practice Address - Street 1:501 LIVE OAK ST
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-7300
Practice Address - Country:US
Practice Address - Phone:386-274-0250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK31333208600000X
FLME162877208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery