Provider Demographics
NPI:1356740872
Name:SCORDO, TAMARA
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:SCORDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6527 CORNWALL CT
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-3104
Mailing Address - Country:US
Mailing Address - Phone:734-812-9756
Mailing Address - Fax:
Practice Address - Street 1:6527 CORNWALL CT
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-3104
Practice Address - Country:US
Practice Address - Phone:734-812-9756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-20
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3115999390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH31159999Medicaid