Provider Demographics
NPI:1144217514
Name:KAUFMAN, ILENE S (MD)
Entity Type:Individual
Prefix:
First Name:ILENE
Middle Name:S
Last Name:KAUFMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 SE 3RD AVE
Mailing Address - Street 2:THIRD FLOOR CBO-PBO
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-2564
Mailing Address - Country:US
Mailing Address - Phone:954-462-8323
Mailing Address - Fax:954-463-1149
Practice Address - Street 1:789 S FEDERAL HWY
Practice Address - Street 2:SUITE 102
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-1245
Practice Address - Country:US
Practice Address - Phone:954-462-8323
Practice Address - Fax:954-463-1149
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0077144208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL257881600Medicaid
FLHW795ZMedicare PIN