Provider Demographics
NPI:1881797397
Name:TARA, PAKORN (MD)
Entity type:Individual
Prefix:
First Name:PAKORN
Middle Name:
Last Name:TARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8687 CONNECTICUT ST
Mailing Address - Street 2:SUITE F
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-6361
Mailing Address - Country:US
Mailing Address - Phone:219-769-7800
Mailing Address - Fax:219-755-0748
Practice Address - Street 1:8687 CONNECTICUT ST
Practice Address - Street 2:SUITE F
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6361
Practice Address - Country:US
Practice Address - Phone:219-769-7800
Practice Address - Fax:219-755-0748
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010-31666208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
387190DMedicare ID - Type Unspecified
E46568Medicare UPIN