Provider Demographics
NPI:1790706711
Name:TARDO, CARMELA LYDIA (MD)
Entity Type:Individual
Prefix:
First Name:CARMELA
Middle Name:LYDIA
Last Name:TARDO
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:PO BOX 44008
Mailing Address - Street 2:UFJP PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6271 SAINT AUGUSTINE RD
Practice Address - Street 2:UFJP DEVELOPMENTAL PEDIATRICS
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-2523
Practice Address - Country:US
Practice Address - Phone:904-633-0750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMFC16402084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000692000Medicaid
LA1155233Medicaid
GA457723146AMedicaid
LA1155233Medicaid
FLBL485XMedicare PIN