Healthcare Provider Details

I. General information

NPI: 1629045521
Provider Name (Legal Business Name): TAMIKA D USSERY-FREEMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 01/19/2021
Certification Date: 01/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 REDSTONE AVE W STE 390
CRESTVIEW FL
32536-6434
US

IV. Provider business mailing address

4205 BELFORT RD STE 4015
JACKSONVILLE FL
32216-3623
US

V. Phone/Fax

Practice location:
  • Phone: 850-683-5100
  • Fax: 850-683-5102
Mailing address:
  • Phone: 904-450-6014
  • Fax: 904-450-6401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number052846
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME114418
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: