Provider Demographics
NPI:1669950879
Name:HENDERSON-TODERIC, TARAH L (DO)
Entity type:Individual
Prefix:
First Name:TARAH
Middle Name:L
Last Name:HENDERSON-TODERIC
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:TARAH
Other - Middle Name:
Other - Last Name:HENDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:56-117 PUALALEA ST
Mailing Address - Street 2:
Mailing Address - City:KAHUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96731-2052
Mailing Address - Country:US
Mailing Address - Phone:808-293-6236
Mailing Address - Fax:
Practice Address - Street 1:436 CLAIRMONT CT STE 100
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-1765
Practice Address - Country:US
Practice Address - Phone:804-526-2121
Practice Address - Fax:804-504-4634
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2025-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA85873207Q00000X
AL2572207QS0010X
VA0102209788207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine