Provider Demographics
NPI:1295849552
Name:THETHI, TINA KAUR (MD)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:KAUR
Last Name:THETHI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 N ORANGE AVE STE 502
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-5503
Mailing Address - Country:US
Mailing Address - Phone:407-303-2801
Mailing Address - Fax:407-303-2805
Practice Address - Street 1:2415 N ORANGE AVE STE 502
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-5503
Practice Address - Country:US
Practice Address - Phone:407-303-2801
Practice Address - Fax:407-303-2805
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15709R207RE0101X
FLME141391207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1070840Medicaid
I66049Medicare UPIN
LA1070840Medicaid