Provider Demographics
NPI:1669639266
Name:FYNN, THERESA ADADZEWA (MD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:ADADZEWA
Last Name:FYNN
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 1:3004 17TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-6011
Mailing Address - Country:US
Mailing Address - Phone:407-593-2910
Mailing Address - Fax:407-593-2913
Practice Address - Street 1:3004 17TH ST
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-6011
Practice Address - Country:US
Practice Address - Phone:407-593-2910
Practice Address - Fax:407-593-2913
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-21
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME109189174400000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFF833Y,FF833XMedicare PIN