Provider Demographics
NPI:1316976806
Name:TANDATNICK, CARL A (MD)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:A
Last Name:TANDATNICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 2ND AVE SW
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33770-3120
Mailing Address - Country:US
Mailing Address - Phone:727-584-7706
Mailing Address - Fax:727-585-4619
Practice Address - Street 1:1301 2ND AVE SW
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-3120
Practice Address - Country:US
Practice Address - Phone:727-584-7706
Practice Address - Fax:727-585-4619
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME52151207LP2900X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D21004Medicare UPIN
04964XMedicare ID - Type Unspecified