Healthcare Provider Details

I. General information

NPI: 1891436010
Provider Name (Legal Business Name): JAKE TENEWITZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2022
Last Update Date: 09/21/2023
Certification Date: 09/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 MALABAR RD
MALABAR FL
32950-3112
US

IV. Provider business mailing address

PO BOX 1137
MELBOURNE FL
32902-1137
US

V. Phone/Fax

Practice location:
  • Phone: 321-241-6800
  • Fax: 321-241-6890
Mailing address:
  • Phone: 321-952-9696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME164364
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: