Provider Demographics
NPI:1144302845
Name:WEGRYN, TARA L (MD)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:WEGRYN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:5116 BISSONNET ST # 202
Mailing Address - Street 2:
Mailing Address - City:BELLAIRE
Mailing Address - State:TX
Mailing Address - Zip Code:77401-4007
Mailing Address - Country:US
Mailing Address - Phone:713-791-9778
Mailing Address - Fax:713-791-9401
Practice Address - Street 1:6400 FANNIN ST
Practice Address - Street 2:SUITE 2295
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-1521
Practice Address - Country:US
Practice Address - Phone:713-791-9778
Practice Address - Fax:713-791-9401
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXJ14252084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX126610804Medicaid
TX8F9210Medicare PIN
TXD20987Medicare UPIN
TX00R75LMedicare PIN