Provider Demographics
NPI:1265728729
Name:VARONI, TARA LORETH (DO)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:LORETH
Last Name:VARONI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26374 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1263
Mailing Address - Country:US
Mailing Address - Phone:906-225-3630
Mailing Address - Fax:906-225-4537
Practice Address - Street 1:710 S LINCOLN RD
Practice Address - Street 2:SUITE 100
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-1292
Practice Address - Country:US
Practice Address - Phone:906-786-4628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI5101019305207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1265728729Medicaid
MIMI6040Medicare PIN