Provider Demographics
NPI:1114983830
Name:TACHE, MARA S (MD)
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:S
Last Name:TACHE
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 1:12221 N MOPAC EXPY
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-2401
Mailing Address - Country:US
Mailing Address - Phone:512-901-4016
Mailing Address - Fax:512-901-3948
Practice Address - Street 1:2400 CEDAR BEND DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-5378
Practice Address - Country:US
Practice Address - Phone:512-901-4016
Practice Address - Fax:512-901-3948
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0638208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX040780101Medicaid
TX370017401Medicare PIN
TX82711KMedicare PIN
TX040780101Medicaid
TX8L25998Medicare PIN