Healthcare Provider Details

I. General information

NPI: 1083867295
Provider Name (Legal Business Name): MARIA U TEDTAOTAO MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2008
Last Update Date: 04/28/2022
Certification Date: 04/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1303 MOSLEY DR
LYNN HAVEN FL
32444-5625
US

IV. Provider business mailing address

1303 MOSLEY DR
LYNN HAVEN FL
32444-5625
US

V. Phone/Fax

Practice location:
  • Phone: 850-271-5996
  • Fax: 850-271-4088
Mailing address:
  • Phone: 850-271-5996
  • Fax: 850-271-4088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberME72254
License Number StateFL

VIII. Authorized Official

Name: MRS. CINDY TAYLOR
Title or Position: BUSINESS MANAGER
Credential:
Phone: 850-271-5996