Healthcare Provider Details

I. General information

NPI: 1588004063
Provider Name (Legal Business Name): TRISTAN N REDDICK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRISTAN N BYRD MD

II. Dates (important events)

Enumeration Date: 06/28/2013
Last Update Date: 04/30/2024
Certification Date: 04/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2906 17TH ST
SAINT CLOUD FL
34769-6006
US

IV. Provider business mailing address

2906 17TH ST
SAINT CLOUD FL
34769-6006
US

V. Phone/Fax

Practice location:
  • Phone: 321-841-7856
  • Fax: 321-843-6432
Mailing address:
  • Phone: 321-841-7856
  • Fax: 321-843-6432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME128691
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: