Provider Demographics
NPI:1235117342
Name:TANNENBAUM, ALAN L (MD)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:L
Last Name:TANNENBAUM
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 1:523 CAPE CORAL PKWY E
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-8545
Mailing Address - Country:US
Mailing Address - Phone:239-549-2772
Mailing Address - Fax:239-549-2332
Practice Address - Street 1:523 CAPE CORAL PKWY E
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-8545
Practice Address - Country:US
Practice Address - Phone:239-549-2772
Practice Address - Fax:239-549-2332
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-09
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69039207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME69039OtherLIC
650692105OtherTIN
FL27851ZMedicare ID - Type Unspecified
FLME69039OtherLIC