Provider Demographics
NPI:1548720121
Name:FORMISANO, TARA MARIE (DO)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:MARIE
Last Name:FORMISANO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 OKATIE HWY
Mailing Address - Street 2:
Mailing Address - City:OKATIE
Mailing Address - State:SC
Mailing Address - Zip Code:29909-3963
Mailing Address - Country:US
Mailing Address - Phone:843-987-7400
Mailing Address - Fax:
Practice Address - Street 1:1264 RIBAUT RD
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-6123
Practice Address - Country:US
Practice Address - Phone:843-987-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2025-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC94477207V00000X
MA1015917207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine