Provider Demographics
NPI:1568544054
Name:TEPEDINO, MIGUEL JOSE (MD)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:JOSE
Last Name:TEPEDINO
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 1:1722 SW NEWLAND WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-6915
Mailing Address - Country:US
Mailing Address - Phone:386-754-4111
Mailing Address - Fax:386-754-4118
Practice Address - Street 1:1722 SW NEWLAND WAY
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-6915
Practice Address - Country:US
Practice Address - Phone:386-754-4111
Practice Address - Fax:386-754-4118
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME101844207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001314100Medicaid
FLCC589AMedicare PIN
FL001314100Medicaid
CC591YMedicare PIN