Provider Demographics
NPI:1952659880
Name:NATHANIEL, TARA JANE (OD)
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:JANE
Last Name:NATHANIEL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 OTTAWA DR
Mailing Address - Street 2:
Mailing Address - City:OSCODA
Mailing Address - State:MI
Mailing Address - Zip Code:48750-1430
Mailing Address - Country:US
Mailing Address - Phone:989-335-0320
Mailing Address - Fax:
Practice Address - Street 1:136 S MAIN ST
Practice Address - Street 2:
Practice Address - City:EATON RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:48827-1068
Practice Address - Country:US
Practice Address - Phone:517-663-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-27
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004734152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist