1396799383 NPI number — JAROSLAV F ONDRUSEK MD

Table of content: JAROSLAV F ONDRUSEK MD (NPI 1396799383)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396799383 NPI number — JAROSLAV F ONDRUSEK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ONDRUSEK
Provider First Name:
JAROSLAV
Provider Middle Name:
F
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:
ONDRUSEK
Provider Other First Name:
JERRY
Provider Other Middle Name:
F
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1396799383
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/19/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2598 NW 27TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOCA RATON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33434-3654
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-303-3750
Provider Business Mailing Address Fax Number:
954-343-1016

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2817 EAST OAKLAND PARK BLVD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
FORT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33306-1889
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-302-3750
Provider Business Practice Location Address Fax Number:
954-343-1016
Provider Enumeration Date:
05/22/2006

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: 207RI0200X , with the licence number:  ME69418 , 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: 379380000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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