Basic Information
| Provider Information | |||||||||
| NPI: | 1619908704 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TABUTEAU | ||||||||
| FirstName: | JEAN | ||||||||
| MiddleName: | CLAUDE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D., M.P.H. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7023 LAKE ISLAND DR | ||||||||
| Address2: | |||||||||
| City: | LAKE WORTH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334677950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5619674252 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 345 S CONGRESS AVE | ||||||||
| Address2: | |||||||||
| City: | DELRAY BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334454617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5612743100 | ||||||||
| FaxNumber: | 5612743144 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 01/02/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083P0901X | ME47425 | FL | Y | Allopathic & Osteopathic Physicians | Preventive Medicine | Public Health & General Preventive Medicine |
ID Information
| ID | Type | State | Issuer | Description | 56161Z | 01 | FL | MEDICARE PTAN | OTHER | 0428906-00 | 05 | FL | MEDICAID |