Provider Demographics
NPI:1285626382
Name:TVEDTEN, TY L (DO)
Entity Type:Individual
Prefix:
First Name:TY
Middle Name:L
Last Name:TVEDTEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:TYRONE
Other - Middle Name:L
Other - Last Name:TVEDTEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:12020 SEMINOLE BLVD
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33778-2805
Mailing Address - Country:US
Mailing Address - Phone:727-588-9572
Mailing Address - Fax:727-584-3832
Practice Address - Street 1:12020 SEMINOLE BLVD
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33778-2805
Practice Address - Country:US
Practice Address - Phone:727-588-9572
Practice Address - Fax:727-584-3832
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS6788207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL80960OtherBLUE CROSS
FL80960OtherBLUE CROSS
F92290Medicare UPIN