1295088383 NPI number — JOG PA

Table of content: (NPI 1295088383)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295088383 NPI number — JOG PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOG PA
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:
1295088383
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
210 JUPITER LAKES BLVD STE 4101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JUPITER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33458-7190
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-747-3777
Provider Business Mailing Address Fax Number:
561-746-4720

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
210 JUPITER LAKES BLVD STE 4101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JUPITER
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33458-7190
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-747-3777
Provider Business Practice Location Address Fax Number:
561-746-4720
Provider Enumeration Date:
10/26/2012

Additional Information

Authorized Official

Authorized Official Last Name:
FELD
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
WARD
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
561-747-3777

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  ME32414 , 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: 010426900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com