MEDICARE: TABITHA E THODE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207PS0010X	Sports Medicine (Emergency Medicine) Physician	AL6607	FL
2	2255A2300X	Athletic Trainer	AL6607	FL
3	2255A2300X	Athletic Trainer	2902	AL

General Provider Information

NPI Number	:	1265086250
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TABITHA E THODE

Provider Business Mailing Address
First Line	:	5235 CHRISTIANCY AVE
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32127-5571
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3447 GAVESON CT
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32129-3122
Country	:	US
Telephone Number	:	386-366-2477
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2019
Last Update Date	:	07/17/2024

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Directions to “ TABITHA E THODE ” Practice Location

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