Healthcare Provider Details

I. General information

NPI: 1699123968
Provider Name (Legal Business Name): TRISTAN A IMHOF MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2016
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2570 RACE TRACK ROAD SUITE A
SAINT JOHNS FL
32259
US

IV. Provider business mailing address

PO BOX 3266
SAINT AUGUSTINE FL
32085-3266
US

V. Phone/Fax

Practice location:
  • Phone: 904-819-1005
  • Fax: 904-819-1002
Mailing address:
  • Phone:
  • Fax: 904-376-4107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMT211126
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101285929
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME141969
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: