Provider Demographics
NPI:1114482494
Name:DOUGLAS M TEW MD LLC
Entity Type:Organization
Organization Name:DOUGLAS M TEW MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:M
Authorized Official - Last Name:TEW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-945-1224
Mailing Address - Street 1:2301 PARK AVE STE 209
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-5558
Mailing Address - Country:US
Mailing Address - Phone:904-945-1224
Mailing Address - Fax:
Practice Address - Street 1:2 PAVILION PLACE
Practice Address - Street 2:
Practice Address - City:PENNEY FARMS
Practice Address - State:FL
Practice Address - Zip Code:32079
Practice Address - Country:US
Practice Address - Phone:904-945-1224
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-31
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty