Healthcare Provider Details

I. General information

NPI: 1720376247
Provider Name (Legal Business Name): TIMOTHY SETH TUDOR D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2011
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 SE HILLMOOR DR STE B-105
PORT ST LUCIE FL
34952-7545
US

IV. Provider business mailing address

1801 SE HILLMOOR DR STE B-105
PORT ST LUCIE FL
34952-7545
US

V. Phone/Fax

Practice location:
  • Phone: 772-398-9911
  • Fax: 772-398-4577
Mailing address:
  • Phone: 772-398-9911
  • Fax: 772-398-4577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number2011017333
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberOS 13941
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: