Provider Demographics
NPI:1356702021
Name:MICHAEL P. TESSLER MD
Entity type:Organization
Organization Name:MICHAEL P. TESSLER MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TESSLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-829-2141
Mailing Address - Street 1:232 SOUTHPARK CIR E
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5137
Mailing Address - Country:US
Mailing Address - Phone:904-829-2141
Mailing Address - Fax:904-829-2141
Practice Address - Street 1:232 SOUTHPARK CIR E
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5137
Practice Address - Country:US
Practice Address - Phone:904-829-2141
Practice Address - Fax:904-829-2141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-09
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME33096208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015004000Medicaid
FL015004000Medicaid