Provider Demographics
NPI:1740481811
Name:MUSSO, TAMARA (MD)
Entity type:Individual
Prefix:DR
First Name:TAMARA
Middle Name:
Last Name:MUSSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10720 E SOUTHERN AVE
Mailing Address - Street 2:SUITE 116
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-3810
Mailing Address - Country:US
Mailing Address - Phone:480-365-0050
Mailing Address - Fax:480-365-0049
Practice Address - Street 1:10720 E SOUTHERN AVE
Practice Address - Street 2:SUITE 116
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-3810
Practice Address - Country:US
Practice Address - Phone:480-365-0050
Practice Address - Fax:480-365-0049
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ37012208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ250599Medicaid