Healthcare Provider Details

I. General information

NPI: 1679763387
Provider Name (Legal Business Name): MICHAEL VINCENT FLORENDO TABLANG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2007
Last Update Date: 02/14/2024
Certification Date: 02/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 N FERDON BLVD
CRESTVIEW FL
32536-2727
US

IV. Provider business mailing address

917 MAR WALT DR
FORT WALTON BEACH FL
32547-6651
US

V. Phone/Fax

Practice location:
  • Phone: 508-623-9798
  • Fax: 850-862-0605
Mailing address:
  • Phone: 850-862-3979
  • Fax: 850-862-0605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberME138845
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: