Healthcare Provider Details

I. General information

NPI: 1336281773
Provider Name (Legal Business Name): MARK J TENHOLDER MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 03/12/2008
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 STE 100
FORT WALTON BEACH FL
32547-6645
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 Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberME89699
License Number StateFL

VIII. Authorized Official

Name: MARK J TENHOLDER
Title or Position: PHYSICIAN
Credential: MD PA
Phone: 850-863-2153