Provider Demographics
NPI: | 1922444785 |
---|---|
Name: | LAND, TARA K (DO) |
Entity Type: | Individual |
Prefix: | |
First Name: | TARA |
Middle Name: | K |
Last Name: | LAND |
Suffix: | |
Gender: | F |
Credentials: | DO |
Other - Prefix: | |
Other - First Name: | TARA |
Other - Middle Name: | K |
Other - Last Name: | SCHULTE |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | |
Mailing Address - Street 1: | 6626 E 75TH ST |
Mailing Address - Street 2: | SUITE 500 |
Mailing Address - City: | INDIANAPOLIS |
Mailing Address - State: | IN |
Mailing Address - Zip Code: | 46250-2805 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 8890 E 116TH ST |
Practice Address - Street 2: | SUITE 300 |
Practice Address - City: | FISHERS |
Practice Address - State: | IN |
Practice Address - Zip Code: | 46038-2856 |
Practice Address - Country: | US |
Practice Address - Phone: | 317-621-1500 |
Practice Address - Fax: | 317-621-1509 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2013-05-20 |
Last Update Date: | 2023-11-27 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
390200000X | ||
IN | 02004582A | 207Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | |
No | 390200000X | Student, Health Care | Student in an Organized Health Care Education/Training Program |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IN | 201171390 | Medicaid | |
IN | P01723966 | Other | RR MEDICARE |
IN | 201171390 | Medicaid |