Provider Demographics
NPI:1568429769
Name:TEW, DOUGLAS MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:MICHAEL
Last Name:TEW
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 1:2035 PROFESSIONAL CTR DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073
Mailing Address - Country:US
Mailing Address - Phone:904-272-0384
Mailing Address - Fax:904-272-6748
Practice Address - Street 1:2035 PROFESSIONAL CTR DR
Practice Address - Street 2:SUITE C
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073
Practice Address - Country:US
Practice Address - Phone:904-272-0384
Practice Address - Fax:904-272-6748
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2010-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0051021207R00000X, 207RC0000X
NC32882207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL048089400Medicaid
FL05931AMedicare ID - Type Unspecified
FL048089400Medicaid