Basic Information
| Provider Information | |||||||||
| NPI: | 1801454491 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAJIK | ||||||||
| FirstName: | AMELIA | ||||||||
| MiddleName: | VERA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 ELM ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029034626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014434992 | ||||||||
| FaxNumber: | 4015377241 | ||||||||
| Practice Location | |||||||||
| Address1: | 593 EDDY ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029034923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014444741 | ||||||||
| FaxNumber: | 4014444445 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2019 | ||||||||
| LastUpdateDate: | 05/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD18489 | RI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.