Provider Demographics
NPI:1871516450
Name:ATANASOFF, TARA LYNN (OD)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:LYNN
Last Name:ATANASOFF
Suffix:
Gender:F
Credentials:OD
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Mailing Address - Street 1:W6989 ANGEL HILL DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54942-9212
Mailing Address - Country:US
Mailing Address - Phone:920-757-6219
Mailing Address - Fax:
Practice Address - Street 1:10 TRI PARK WAY
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-1658
Practice Address - Country:US
Practice Address - Phone:920-831-7942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3011-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIV06627Medicare UPIN