Provider Demographics
NPI:1871621896
Name:FOX, TAMARA BRADSHAW (MD)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:BRADSHAW
Last Name:FOX
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15110 JOHN J DELANEY DR
Practice Address - Street 2:STE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-3544
Practice Address - Country:US
Practice Address - Phone:704-512-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2009-01047207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5912888Medicaid
NCAC5385578R907OtherDEA LICENSE NUMBER
NC127694OtherLICENSE NUMBER
SCN0104GMedicaid
NC1871621896Medicaid
NC127694OtherLICENSE NUMBER
SCAA64447165Medicare PIN
NC2074094Medicare PIN