Provider Demographics
NPI:1003826744
Name:JORGENSEN, ELLEN VERENA (MD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:VERENA
Last Name:JORGENSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:E
Other - Middle Name:VERENA
Other - Last Name:JORGENSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:813-974-2201
Mailing Address - Fax:813-974-4325
Practice Address - Street 1:12901 BRUCE B DOWNS BLVD
Practice Address - Street 2:MDC 15
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-4742
Practice Address - Country:US
Practice Address - Phone:813-974-2583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME544372080P0205X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL035500300Medicaid
FL07816OtherBLUE CROSS BLUE SHIELD
FL07816WMedicare PIN
FL035500300Medicaid