Provider Demographics
NPI:1154380129
Name:CAUDILL-DEATON, TARA J
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:J
Last Name:CAUDILL-DEATON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W 12 MILE ROAD
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-6712
Mailing Address - Country:US
Mailing Address - Phone:248-543-0600
Mailing Address - Fax:248-543-0562
Practice Address - Street 1:1200 W 12 MILE RD
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-4439
Practice Address - Country:US
Practice Address - Phone:248-543-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301080294207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI080F370780OtherBCBSM
MI4815480Medicaid
MI080F370780OtherBCBSM
MI4815480Medicaid