Provider Demographics
NPI:1992963961
Name:TARASOFF, GREGORY JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:JOHN
Last Name:TARASOFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 S EL CAMINO REAL STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-2381
Mailing Address - Country:US
Mailing Address - Phone:650-373-0777
Mailing Address - Fax:
Practice Address - Street 1:2600 S EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-2380
Practice Address - Country:US
Practice Address - Phone:650-373-0777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-27
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA604642084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKH19418Medicare UPIN
MNH19418Medicare UPIN