Provider Demographics
NPI:1669430427
Name:DEYAMPERT, TARA (MD)
Entity type:Individual
Prefix:DR
First Name:TARA
Middle Name:
Last Name:DEYAMPERT
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 1:8900 COLUMBIA 100 PKWY
Mailing Address - Street 2:SUITE E
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-2336
Mailing Address - Country:US
Mailing Address - Phone:410-997-6464
Mailing Address - Fax:410-997-6867
Practice Address - Street 1:8900 COLUMBIA 100 PKWY
Practice Address - Street 2:SUITE E
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-2336
Practice Address - Country:US
Practice Address - Phone:410-997-6464
Practice Address - Fax:410-997-6867
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0046242174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD448300600Medicaid
MD448300600Medicaid