Provider Demographics
NPI:1285679209
Name:TEWATIA, TARUN (MD)
Entity Type:Individual
Prefix:DR
First Name:TARUN
Middle Name:
Last Name:TEWATIA
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:PO BOX 361095
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32936-1095
Mailing Address - Country:US
Mailing Address - Phone:321-253-2900
Mailing Address - Fax:321-435-0100
Practice Address - Street 1:2200 W EAU GALLIE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-3166
Practice Address - Country:US
Practice Address - Phone:321-253-2900
Practice Address - Fax:321-435-0100
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94994208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL37007OtherBLUE SHIELD OF FL
FL274705700Medicaid
FLNC895OtherFL HF MEDICARE
FL37007WMedicare PIN