Individual
L TAN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
2915 MADISON ST, MARIANNA, FL 32446-3449
(850) 526-2460
(850) 482-5450
Mailing address
2915 MADISON ST, MARIANNA, FL 32446-3449
(850) 526-2460
(850) 303-6776
Taxonomy
Speciality
Code
Description
License number
State
208800000X
Urology Physician
ME33964
FL
208D00000X
General Practice Physician
Primary
ME33964
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
123513762
NPI
FL
Enumeration date
05/30/2005
Last updated
07/18/2026
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