Provider Demographics
NPI:1679763387
Name:TABLANG, MICHAEL VINCENT FLORENDO (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL VINCENT
Middle Name:FLORENDO
Last Name:TABLANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:917 MAR WALT DR
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6651
Mailing Address - Country:US
Mailing Address - Phone:850-862-3979
Mailing Address - Fax:850-862-0605
Practice Address - Street 1:351 N FERDON BLVD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-2727
Practice Address - Country:US
Practice Address - Phone:508-623-9798
Practice Address - Fax:850-862-0605
Is Sole Proprietor?:No
Enumeration Date:2007-07-29
Last Update Date:2024-02-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME138845207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL116653900Medicaid
KS200879690CMedicaid