Provider Demographics
NPI:1215062021
Name:WATERBURY, TARA S
Entity type:Individual
Prefix:DR
First Name:TARA
Middle Name:S
Last Name:WATERBURY
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 1:9905 134TH ST E
Mailing Address - Street 2:#11-208
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-5664
Mailing Address - Country:US
Mailing Address - Phone:253-268-0827
Mailing Address - Fax:
Practice Address - Street 1:8705 S TACOMA WAY
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-4544
Practice Address - Country:US
Practice Address - Phone:253-582-3698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA4020TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2031326Medicaid
WA8856739Medicare ID - Type Unspecified
WAV07003Medicare UPIN