Provider Demographics
NPI:1669767240
Name:ORTIZ, TARA K (MD)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:K
Last Name:ORTIZ
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:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5330 OVERPASS RD STE 100
Practice Address - Street 2:
Practice Address - City:BUDA
Practice Address - State:TX
Practice Address - Zip Code:78610-2300
Practice Address - Country:US
Practice Address - Phone:737-999-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-13
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01092934A208800000X
TXS1882208800000X
NC2012-02023208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology