Provider Demographics
NPI:1972716660
Name:RENATA TEYTELBAUM, M.D., P.A.
Entity type:Organization
Organization Name:RENATA TEYTELBAUM, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RENATA
Authorized Official - Middle Name:
Authorized Official - Last Name:TEYTELBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-734-6777
Mailing Address - Street 1:PO BOX 1228
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34697-1228
Mailing Address - Country:US
Mailing Address - Phone:727-734-6777
Mailing Address - Fax:727-734-6440
Practice Address - Street 1:585 MAIN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-4918
Practice Address - Country:US
Practice Address - Phone:727-734-6777
Practice Address - Fax:727-734-6440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME56418207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL40156OtherBLUECROSS BLUE SHIELD
FL09754YMedicare ID - Type Unspecified
FL40156OtherBLUECROSS BLUE SHIELD