Provider Demographics
NPI:1770565699
Name:BLASINGAME, TARA L F (DPM)
Entity type:Individual
Prefix:DR
First Name:TARA
Middle Name:L F
Last Name:BLASINGAME
Suffix:
Gender:F
Credentials:DPM
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 6487
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35813-0487
Mailing Address - Country:US
Mailing Address - Phone:256-772-8566
Mailing Address - Fax:256-774-8211
Practice Address - Street 1:131 W DUBLIN DR
Practice Address - Street 2:SUITE A
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-1787
Practice Address - Country:US
Practice Address - Phone:256-772-8566
Practice Address - Fax:256-774-8211
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALAL164213ES0131X
GA714213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL510452548OtherTRICARE
AL051514659OtherBLUE CROSS BLUE SHIELD
AL890010830Medicaid
AL890010840Medicaid
AL051514658OtherBLUE CROSS BLUE SHIELD
AL051514659OtherBLUE CROSS BLUE SHIELD
AL890010840Medicaid
AL051514658Medicare ID - Type UnspecifiedTHE FOOT GROUP P C