Provider Demographics
NPI:1336315969
Name:TANTOCO, MARY ROSE GOTARDO (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY ROSE
Middle Name:GOTARDO
Last Name:TANTOCO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 NORWICH NEW LONDON TPKE STE 2
Mailing Address - Street 2:
Mailing Address - City:UNCASVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06382-2518
Mailing Address - Country:US
Mailing Address - Phone:860-367-0087
Mailing Address - Fax:
Practice Address - Street 1:88 NORWICH NEW LONDON TPKE STE 2
Practice Address - Street 2:
Practice Address - City:UNCASVILLE
Practice Address - State:CT
Practice Address - Zip Code:06382-2518
Practice Address - Country:US
Practice Address - Phone:860-367-0087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-04
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT62257207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology