Healthcare Provider Details

I. General information

NPI: 1407850878
Provider Name (Legal Business Name): MARK J TENHOLDER MD PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 06/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 MAR WALT DR STE 100
FORT WALTON BEACH FL
32547-6645
US

IV. Provider business mailing address

1034 MAR WALT DR UNIT 100
FORT WALTON BEACH FL
32547-6637
US

V. Phone/Fax

Practice location:
  • Phone: 850-863-2153
  • Fax: 850-863-2885
Mailing address:
  • Phone: 850-863-2153
  • Fax: 850-863-2885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberME89699
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: