Individual
DR. TARA FAWN RAY
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
DO
Contact information
Practice address
400 DIVISION ST, SUITE 3, SOUTH CHARLESTON, WV 25309-1459
(304) 767-7960
(304) 767-7969
Mailing address
PO BOX 9189, SOUTH CHARLESTON, WV 25309-0189
(304) 767-7960
(304) 767-7969
Taxonomy
Speciality
Code
Description
License number
State
2084P0800X
Psychiatry Physician
Primary
2117
WV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
208724900
TAX IDENTIFICATION
WV
01
—
2616995
MEDICAID
OH
05
—
3810002665
—
WV
Enumeration date
06/14/2006
Last updated
05/17/2012
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