1720227523 NPI number — KEJARO MD, PLLC

Table of content: (NPI 1720227523)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720227523 NPI number — KEJARO MD, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KEJARO MD, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720227523
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/07/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4008
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33338-4008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:
954-564-7976

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2825 N STATE ROAD 7
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
MARGATE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33063-5737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-972-4900
Provider Business Practice Location Address Fax Number:
954-917-4940
Provider Enumeration Date:
02/18/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ROBINSON
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
JAMAL
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
954-564-7976

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  A83200 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: ME86367 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0200X , with the licence number: ME86367 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0200X , with the licence number: A83200 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: ME86367 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RP1001X , with the licence number: A83200 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 276264100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".