Provider Demographics
NPI:1962508903
Name:MAURO, TARA CODEE (DO)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:CODEE
Last Name:MAURO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:CODEE
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:11515 EL CAMINO REAL STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-3034
Mailing Address - Country:US
Mailing Address - Phone:858-279-1223
Mailing Address - Fax:858-261-2001
Practice Address - Street 1:11515 EL CAMINO REAL STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-3034
Practice Address - Country:US
Practice Address - Phone:858-279-1223
Practice Address - Fax:858-261-2001
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A164392084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry