Provider Demographics
NPI:1407849342
Name:TEDRICK, DAVID L (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:TEDRICK
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 1:1300 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4646
Mailing Address - Country:US
Mailing Address - Phone:850-216-0100
Mailing Address - Fax:850-201-4834
Practice Address - Street 1:1300 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4646
Practice Address - Country:US
Practice Address - Phone:850-216-0100
Practice Address - Fax:850-201-4834
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME29338207RC0000X, 207RI0011X
GA015832207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009979030Medicaid
FL00000OtherUNITED HEALTH CARE
FL37230OtherBCBS
FL00000OtherFOCUS
FL00000OtherSOUTHCARE
GA00000OtherVISTA
FL00000OtherUNIVERSAL HEALTH CARE
FL00000OtherBEECH STREET/CAPP CARE
FL058454100Medicaid
FL00000OtherHUMANA/CHOICE CARE
GA000164898AMedicaid
FL00000OtherUNITED HEALTH CARE
FL00000OtherSOUTHCARE