Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RI0200X | Infectious Disease | D33866 | MD |
NPI | 1003877093 |
---|---|
Provider Name | Dr. Carol Overton Tacket |
First Address | Baltimore, MD 21264-4442 |
Second Address | Baltimore, MD 21201-1544 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/03/2006 |
Last Update Date | 08/01/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
421719-01 | BLUE CROSS/BLUE SHIELD (01) | MD |
B69797 | (02) |