Provider Demographics
NPI:1316956774
Name:BASTEK, TARA KOPP (MD)
Entity type:Individual
Prefix:DR
First Name:TARA
Middle Name:KOPP
Last Name:BASTEK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:KOPP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3024 NEW BERN AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-1247
Mailing Address - Country:US
Mailing Address - Phone:919-350-8228
Mailing Address - Fax:919-350-7976
Practice Address - Street 1:3000 NEW BERN AVE
Practice Address - Street 2:NEONATOLOGY DEPT.
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1231
Practice Address - Country:US
Practice Address - Phone:919-350-8545
Practice Address - Fax:919-350-8146
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9900162208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891203CMedicaid
G99433Medicare UPIN
NC2033507Medicare ID - Type Unspecified