Provider Demographics
NPI:1497756621
Name:TEYTELBAUM, RENATA (MD)
Entity Type:Individual
Prefix:
First Name:RENATA
Middle Name:
Last Name:TEYTELBAUM
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 1:585 MAIN STREET, SUITE 101
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34698-4921
Mailing Address - Country:US
Mailing Address - Phone:727-734-6777
Mailing Address - Fax:727-734-6440
Practice Address - Street 1:585 MAIN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-4918
Practice Address - Country:US
Practice Address - Phone:727-734-6777
Practice Address - Fax:727-734-6440
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0056418207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL053130800Medicaid
FL09754YMedicare PIN
FL053130800Medicaid