Basic Information
| Provider Information | |||||||||
| NPI: | 1629045521 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | USSERY-FREEMAN | ||||||||
| FirstName: | TAMIKA | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4205 BELFORT RD STE 4015 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322163623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044506014 | ||||||||
| FaxNumber: | 9044506401 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 REDSTONE AVE W STE 390 | ||||||||
| Address2: | |||||||||
| City: | CRESTVIEW | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325366434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506835100 | ||||||||
| FaxNumber: | 8506835102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2006 | ||||||||
| LastUpdateDate: | 01/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 052846 | GA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | ME114418 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 406306123A | 05 | GA | MEDICAID |