Provider Demographics
NPI:1699961656
Name:SCHULTE, TARA DAWN (DO)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:DAWN
Last Name:SCHULTE
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 1:1300 S GEYER RD
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-7112
Mailing Address - Country:US
Mailing Address - Phone:440-879-0081
Mailing Address - Fax:440-879-0084
Practice Address - Street 1:6420 CLAYTON RD
Practice Address - Street 2:
Practice Address - City:RICHMOND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63117-1811
Practice Address - Country:US
Practice Address - Phone:314-768-8360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-24
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2008018169207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1699961656Medicaid