Provider Demographics
NPI:1538264767
Name:TARKA, EDWARD M (DPM)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:M
Last Name:TARKA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 WAWECUS ST
Mailing Address - Street 2:109
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-2160
Mailing Address - Country:US
Mailing Address - Phone:860-887-3538
Mailing Address - Fax:860-887-1394
Practice Address - Street 1:79 WAWECUS ST
Practice Address - Street 2:109
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2160
Practice Address - Country:US
Practice Address - Phone:860-887-3538
Practice Address - Fax:860-887-1394
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000570213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT480000603Medicare ID - Type Unspecified
CTT87069Medicare UPIN