Provider Demographics
NPI:1326692781
Name:TINE, STEPHANIE (DPM)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:
Last Name:TINE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3051 NE 41ST ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-5801
Mailing Address - Country:US
Mailing Address - Phone:954-594-2610
Mailing Address - Fax:
Practice Address - Street 1:4801 N FEDERAL HWY STE 101
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4618
Practice Address - Country:US
Practice Address - Phone:754-444-9258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE5796213ES0103X
FLPO4341213ES0103X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery