Provider Demographics
NPI:1447208657
Name:FACKLER, TAMARA K (MD)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:K
Last Name:FACKLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2002 MEDICAL PKWY
Mailing Address - Street 2:SUITE 320
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3046
Mailing Address - Country:US
Mailing Address - Phone:410-571-8733
Mailing Address - Fax:410-571-6309
Practice Address - Street 1:2002 MEDICAL PKWY
Practice Address - Street 2:SUITE 320
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3046
Practice Address - Country:US
Practice Address - Phone:410-571-8733
Practice Address - Fax:410-571-6309
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD0047532207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD318402100Medicaid
MD967LM493Medicare ID - Type Unspecified
MD318402100Medicaid