Provider Demographics
NPI:1306165295
Name:CHILAKAMARRI, TARA (MD)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:CHILAKAMARRI
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 1:2101 MONTOPOLIS DR UNIT 20
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78741-6509
Mailing Address - Country:US
Mailing Address - Phone:314-755-8482
Mailing Address - Fax:
Practice Address - Street 1:919 E 32ND ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-2703
Practice Address - Country:US
Practice Address - Phone:512-544-5116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-18
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015032305208100000X
KY51357208100000X
TN58141208100000X
NC2013-02427208100000X
390200000X
TXR4818208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1306165295Medicaid
IN300017310Medicaid
KY7100556760Medicaid
SCNC2127Medicaid