Provider Demographics
NPI:1184674624
Name:TENNISWOOD, DAVID L (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:TENNISWOOD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:904-450-6014
Mailing Address - Fax:904-450-6401
Practice Address - Street 1:619 N COVE BLVD
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-3642
Practice Address - Country:US
Practice Address - Phone:850-913-6960
Practice Address - Fax:850-913-6961
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2020-03-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KS0428049208600000X
FLME108539208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G90568Medicare UPIN