Provider Demographics
NPI:1487954723
Name:VON TOBEL, TRAVIS RANDALL (MD)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:RANDALL
Last Name:VON TOBEL
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 1:4100 SOUTHPOINT DR E STE 1
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-8710
Mailing Address - Country:US
Mailing Address - Phone:904-647-5266
Mailing Address - Fax:904-770-5594
Practice Address - Street 1:4100 SOUTHPOINT DR E STE 1
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-8710
Practice Address - Country:US
Practice Address - Phone:904-647-5266
Practice Address - Fax:904-770-5594
Is Sole Proprietor?:No
Enumeration Date:2010-11-02
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY244805208600000X
FLME117856208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014945000Medicaid