Provider Demographics
NPI:1912296120
Name:GIBSON, TARA LYNN (MD)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:LYNN
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:LYNN
Other - Last Name:AMATO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10751 GLEN ELLEN DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-5060
Mailing Address - Country:US
Mailing Address - Phone:813-451-7672
Mailing Address - Fax:
Practice Address - Street 1:12901 BRUCE B DOWNS BLVD # 41
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-4742
Practice Address - Country:US
Practice Address - Phone:813-844-7412
Practice Address - Fax:813-844-7995
Is Sole Proprietor?:No
Enumeration Date:2011-03-29
Last Update Date:2014-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME119861207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program