Provider Demographics
NPI:1770532293
Name:CUDA, TARA LYN (DO)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:LYN
Last Name:CUDA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2230 SOUTH BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145
Mailing Address - Country:US
Mailing Address - Phone:215-755-2800
Mailing Address - Fax:215-755-3300
Practice Address - Street 1:2230 SOUTH BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145
Practice Address - Country:US
Practice Address - Phone:215-334-3869
Practice Address - Fax:215-755-3300
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA05008552L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001666331Medicaid
PA001666331Medicaid
G59800Medicare UPIN
PA002004Medicare PIN