Provider Demographics
NPI:1164483780
Name:FIDEL, JEFFREY ROSS (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ROSS
Last Name:FIDEL
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 1:951 NW 13TH ST
Mailing Address - Street 2:SUITE 1C
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33486-2359
Mailing Address - Country:US
Mailing Address - Phone:561-447-9341
Mailing Address - Fax:561-447-9352
Practice Address - Street 1:951 NW 13TH ST
Practice Address - Street 2:SUITE 1C
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33486-2359
Practice Address - Country:US
Practice Address - Phone:561-447-9341
Practice Address - Fax:561-447-9352
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL883422085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268314800Medicaid
FL268314800Medicaid
FL81875TMedicare PIN