1356320048 NPI number — GEORGE BRINNIG JASTRZEBSKI MD

Table of content: GEORGE BRINNIG JASTRZEBSKI MD (NPI 1356320048)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356320048 NPI number — GEORGE BRINNIG JASTRZEBSKI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JASTRZEBSKI
Provider First Name:
GEORGE
Provider Middle Name:
BRINNIG
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRINNIG
Provider Other First Name:
GEORGE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1356320048
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1360 E VENICE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VENICE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34285-9066
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-480-2135
Provider Business Mailing Address Fax Number:
941-484-2200

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 NEAPOLITAN WAY
Provider Second Line Business Practice Location Address:
MONTGOMERY EYE CENTER
Provider Business Practice Location Address City Name:
NAPLES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34103-8570
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-261-8383
Provider Business Practice Location Address Fax Number:
239-261-8443
Provider Enumeration Date:
01/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  045360 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: ME 124499 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4221675 . This is a "AETNA/US HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: A36482 . This is a "MEDICARE B" identifier . This identifiers is of the category "OTHER".
  • Identifier: J27482 . This is a "BLUE SHIELD HMO BLUE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2035031 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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