Provider Demographics
NPI:1023186467
Name:TANTIVIT, PHUKET (MD)
Entity Type:Individual
Prefix:
First Name:PHUKET
Middle Name:
Last Name:TANTIVIT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5955 PONCE DE LEON BLVD
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-2423
Mailing Address - Country:US
Mailing Address - Phone:305-662-8668
Mailing Address - Fax:305-662-3723
Practice Address - Street 1:5955 PONCE DE LEON BLVD
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-2423
Practice Address - Country:US
Practice Address - Phone:305-662-8668
Practice Address - Fax:305-662-3723
Is Sole Proprietor?:No
Enumeration Date:2006-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 804742080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL260 097 800Medicaid