Provider Demographics
NPI:1144331521
Name:TARASKEVICH, DAVID MARK (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MARK
Last Name:TARASKEVICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:237 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-4407
Mailing Address - Country:US
Mailing Address - Phone:203-237-2200
Mailing Address - Fax:203-630-0655
Practice Address - Street 1:237 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-4407
Practice Address - Country:US
Practice Address - Phone:203-237-2200
Practice Address - Fax:203-630-0655
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT023754207Q00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTB84638Medicare UPIN