Provider Demographics
NPI:1669984167
Name:TATUM, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:TATUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4230 SW CALLICOE ST
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-3189
Mailing Address - Country:US
Mailing Address - Phone:772-370-5547
Mailing Address - Fax:
Practice Address - Street 1:6905 HERITAGE DR
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-8227
Practice Address - Country:US
Practice Address - Phone:772-370-5547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-25
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities