1679763387 NPI number — MICHAEL VINCENT FLORENDO TABLANG M.D.

Table of content: MICHAEL VINCENT FLORENDO TABLANG M.D. (NPI 1679763387)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679763387 NPI number — MICHAEL VINCENT FLORENDO TABLANG M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TABLANG
Provider First Name:
MICHAEL VINCENT
Provider Middle Name:
FLORENDO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679763387
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/14/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
917 MAR WALT DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WALTON BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32547-6651
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-862-3979
Provider Business Mailing Address Fax Number:
850-862-0605

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
351 N FERDON BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRESTVIEW
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32536-2727
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-623-9798
Provider Business Practice Location Address Fax Number:
850-862-0605
Provider Enumeration Date:
07/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X , with the licence number:  ME138845 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 116653900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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