Provider Demographics
NPI:1386962215
Name:KATZ, TARA (DO)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:KATZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 N ANDOVER RD
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:KS
Mailing Address - Zip Code:67002-9778
Mailing Address - Country:US
Mailing Address - Phone:316-733-6618
Mailing Address - Fax:316-733-5299
Practice Address - Street 1:612 N ANDOVER RD
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:KS
Practice Address - Zip Code:67002-9778
Practice Address - Country:US
Practice Address - Phone:316-733-6618
Practice Address - Fax:316-733-5299
Is Sole Proprietor?:No
Enumeration Date:2010-05-17
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-36048207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201072060AMedicaid
KS003719267Medicare Oscar/Certification