1790784270 NPI number — JACK STEVEN DAUBERT MD

Table of content: JACK STEVEN DAUBERT MD (NPI 1790784270)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790784270 NPI number — JACK STEVEN DAUBERT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAUBERT
Provider First Name:
JACK
Provider Middle Name:
STEVEN
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:
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:
1790784270
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1050 SE MONTERRY RD
Provider Second Line Business Mailing Address:
STE #104
Provider Business Mailing Address City Name:
STUART
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34994-4512
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-283-2020
Provider Business Mailing Address Fax Number:
772-220-9582

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1050 SE MONTERRY RD
Provider Second Line Business Practice Location Address:
STE #104
Provider Business Practice Location Address City Name:
STUART
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34994-4512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-283-2020
Provider Business Practice Location Address Fax Number:
772-220-9582
Provider Enumeration Date:
07/18/2005

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:  ME0055247 , 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: 08501 . This is a "BCBS OF FLORIDA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 062348200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 08501V . This is a "MEDICARE RETIRED RAILROAD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 08501U . This is a "MEDICARE RETIRED RAILROAD" identifier . This identifiers is of the category "OTHER".




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