1669659926 NPI number — JEREMY GALLEGO ECKSTEIN M.D

Table of content: JEREMY GALLEGO ECKSTEIN M.D (NPI 1669659926)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669659926 NPI number — JEREMY GALLEGO ECKSTEIN M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GALLEGO ECKSTEIN
Provider First Name:
JEREMY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ECKSTEIN
Provider Other First Name:
JEREMY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1669659926
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/26/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2900 CORPORATE WAY
Provider Second Line Business Mailing Address:
DOOR D
Provider Business Mailing Address City Name:
MIRAMAR
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33025-3925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-276-5685
Provider Business Mailing Address Fax Number:
954-985-7074

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4651 SHERIDAN ST
Provider Second Line Business Practice Location Address:
SUITE 350
Provider Business Practice Location Address City Name:
HOLLYWOOD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33021-3457
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-966-8559
Provider Business Practice Location Address Fax Number:
954-966-9762
Provider Enumeration Date:
01/29/2008

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: 208600000X , with the licence number:  ME101793 , 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: 000225200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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