Provider Demographics
NPI:1659481521
Name:MADURO, TARA MARIE
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:MARIE
Last Name:MADURO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3804 DOGTROT ST
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-2063
Mailing Address - Country:US
Mailing Address - Phone:727-376-8893
Mailing Address - Fax:
Practice Address - Street 1:1807 SHORT BRANCH DR
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34655-4424
Practice Address - Country:US
Practice Address - Phone:727-372-0182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
FLPT17785225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT17785OtherLICENSE#