Healthcare Provider Details

I. General information

NPI: 1184674624
Provider Name (Legal Business Name): DAVID L TENNISWOOD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 03/03/2020
Certification Date: 03/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 N COVE BLVD
PANAMA CITY FL
32401-3642
US

IV. Provider business mailing address

4205 BELFORT RD STE 4015
JACKSONVILLE FL
32216-3623
US

V. Phone/Fax

Practice location:
  • Phone: 850-913-6960
  • Fax: 850-913-6961
Mailing address:
  • Phone: 904-450-6014
  • Fax: 904-450-6401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0428049
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME108539
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: