Provider Demographics
NPI:1104836972
Name:JARRETT, WENTWORTH GRANTLEY (MD)
Entity Type:Individual
Prefix:
First Name:WENTWORTH
Middle Name:GRANTLEY
Last Name:JARRETT
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 1:12955 SW 132ND ST
Mailing Address - Street 2:BLDG 3B SUITE 104
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-7205
Mailing Address - Country:US
Mailing Address - Phone:305-520-5750
Mailing Address - Fax:305-520-5754
Practice Address - Street 1:12955 SW 132ND ST
Practice Address - Street 2:BLDG 3B SUITE 104
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-7205
Practice Address - Country:US
Practice Address - Phone:305-520-5750
Practice Address - Fax:305-520-5754
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME48820207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL046128800Medicaid
FL046128800Medicaid
FLD20890Medicare UPIN