Provider Demographics
NPI:1770572380
Name:TARA, MONA MYNNEL (MD)
Entity type:Individual
Prefix:
First Name:MONA
Middle Name:MYNNEL
Last Name:TARA
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 1:714 NW 5TH ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1529
Mailing Address - Country:US
Mailing Address - Phone:541-244-2292
Mailing Address - Fax:541-244-2292
Practice Address - Street 1:714 NW 5TH ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1529
Practice Address - Country:US
Practice Address - Phone:541-244-2292
Practice Address - Fax:541-244-2292
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-17
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD15235207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORE98978Medicare UPIN