Healthcare Provider Details

I. General information

NPI: 1316976806
Provider Name (Legal Business Name): CARL A TANDATNICK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 02/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 2ND AVE SW
LARGO FL
33770-3120
US

IV. Provider business mailing address

1301 2ND AVE SW
LARGO FL
33770-3120
US

V. Phone/Fax

Practice location:
  • Phone: 727-584-7706
  • Fax: 727-585-4619
Mailing address:
  • Phone: 727-584-7706
  • Fax: 727-585-4619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberME52151
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberME52151
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: