Provider Demographics
NPI:1780694489
Name:GELLASCH, TARA L (MD)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:GELLASCH
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 1:1250 DRIVING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NY
Mailing Address - Zip Code:14513-1057
Mailing Address - Country:US
Mailing Address - Phone:315-332-2427
Mailing Address - Fax:315-332-2324
Practice Address - Street 1:1250 DRIVING PARK AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513-1057
Practice Address - Country:US
Practice Address - Phone:315-332-2427
Practice Address - Fax:315-332-2324
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101237926207V00000X
NY253197207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03105295Medicaid
NYJ400068849Medicare PIN
NY03105295Medicaid
NYJ400072002Medicare PIN
NYJ400004813Medicare PIN