Provider Demographics
NPI:1396812244
Name:FUSCO, TARA M (MD)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:M
Last Name:FUSCO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:M
Other - Last Name:MODY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:8120 WOODMAN AVE
Mailing Address - Street 2:
Mailing Address - City:PANORAMA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91402
Mailing Address - Country:US
Mailing Address - Phone:818-815-5193
Mailing Address - Fax:
Practice Address - Street 1:8120 WOODMAN
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-5423
Practice Address - Country:US
Practice Address - Phone:818-815-5193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG80228207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine