Healthcare Provider Details

I. General information

NPI: 1780812586
Provider Name (Legal Business Name): AIMEE LYNN TIEU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AIMEE LYNN SMITH MD

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 03/19/2020
Certification Date: 03/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8725 N WICKHAM RD SUITE 302
MELBOURNE FL
32940-2239
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 321-434-9561
  • Fax: 321-434-9231
Mailing address:
  • Phone: 321-434-9561
  • Fax: 321-434-9231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License NumberME104414
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberME104414
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code2088F0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Urology) Physician
License NumberME104414
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: