Provider Demographics
NPI:1003841263
Name:KRAVITZ, JACK A (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:A
Last Name:KRAVITZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2825 N STATE RD 7
Mailing Address - Street 2:#304
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33063
Mailing Address - Country:US
Mailing Address - Phone:954-977-4101
Mailing Address - Fax:954-977-6650
Practice Address - Street 1:2825 N STATE RD 7
Practice Address - Street 2:#304
Practice Address - City:MARGATE
Practice Address - State:FL
Practice Address - Zip Code:33063
Practice Address - Country:US
Practice Address - Phone:954-977-4101
Practice Address - Fax:954-977-6650
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0041286207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL049067900Medicaid
D63248Medicare UPIN
FL94475AMedicare ID - Type Unspecified