1730160615 NPI number — DR. MARK JAFFE M.D.

Employer Identification Number (EIN)	:
Provider Organization Name (Legal Business Name)	:
Provider Last Name (Legal Name)	:	JAFFE
Provider First Name	:	MARK
Provider Middle Name	:
Provider Name Prefix Text	:	DR.
Provider Name Suffix Text	:
Provider Credential Text	:	M.D.
Provider Gender Code	:	M

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	:	1730160615
Entity Type Code	:	Individual
Replacement NPI	:
Last Update Date	:	06/14/2010
NPI Deactivation Reason Code	:
NPI Deactivation Date	:
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Provider First Line Business Mailing Address	:	1 SW 129TH AVE
Provider Second Line Business Mailing Address	:	SUITE 401
Provider Business Mailing Address City Name	:	PEMBROKE PINES
Provider Business Mailing Address State Name	:	FL
Provider Business Mailing Address Postal Code	:	330271761
Provider Business Mailing Address Country Code	:	US
Provider Business Mailing Address Telephone Number	:	9544419995
Provider Business Mailing Address Fax Number	:	9544419033

Provider First Line Business Practice Location Address	:	1 SW 129TH AVE
Provider Second Line Business Practice Location Address	:	SUITE 401
Provider Business Practice Location Address City Name	:	PEMBROKE PINES
Provider Business Practice Location Address State Name	:	FL
Provider Business Practice Location Address Postal Code	:	330271761
Provider Business Practice Location Address Country Code	:	US
Provider Business Practice Location Address Telephone Number	:	9544419995
Provider Business Practice Location Address Fax Number	:	9544419033
Provider Enumeration Date	:	11/08/2005

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

• Taxonomy code: 174400000X , with the licence number:  0068879 , registered in the state of FL .

• Identifier: 28291 , issued by the state of ( FL ) . This identifiers is of the category "".
• Identifier: 379137800 , issued by the state of ( FL ) . This identifiers is of the category "".
• Identifier: G22211 , issued by the state of ( FL ) . This identifiers is of the category "".