Healthcare Provider Details

I. General information

NPI: 1205897030
Provider Name (Legal Business Name): IVAN TARLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 03/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 N MILLS AVE
ORLANDO FL
32803-1432
US

IV. Provider business mailing address

1911 N MILLS AVE
ORLANDO FL
32803-1432
US

V. Phone/Fax

Practice location:
  • Phone: 407-893-8200
  • Fax: 407-893-8220
Mailing address:
  • Phone: 407-893-8200
  • Fax: 407-893-8220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME75834
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: