Provider Demographics
NPI:1871831560
Name:JEFFREY L TEDDER, MD, PA
Entity Type:Organization
Organization Name:JEFFREY L TEDDER, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:L
Authorized Official - Last Name:TEDDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-522-8838
Mailing Address - Street 1:5015 4TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-2901
Mailing Address - Country:US
Mailing Address - Phone:727-522-8838
Mailing Address - Fax:727-520-0292
Practice Address - Street 1:5015 4TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33703-2901
Practice Address - Country:US
Practice Address - Phone:727-522-8838
Practice Address - Fax:727-520-0292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-30
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0062879174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE91808Medicare UPIN