Provider Demographics
NPI:1164630091
Name:JEFFREY S GOTTFRIED DO PA
Entity Type:Organization
Organization Name:JEFFREY S GOTTFRIED DO PA
Other - Org Name:FORT PIERCE WALK IN MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:STUART
Authorized Official - Last Name:GOTTRIED
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:772-464-6551
Mailing Address - Street 1:900 VIRGINIA AVE
Mailing Address - Street 2:SUITE 10
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-5882
Mailing Address - Country:US
Mailing Address - Phone:772-464-6551
Mailing Address - Fax:772-465-0322
Practice Address - Street 1:900 VIRGINIA AVE
Practice Address - Street 2:SUITE 10
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-5882
Practice Address - Country:US
Practice Address - Phone:772-464-6551
Practice Address - Fax:772-465-0322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0S7057207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK4574Medicare ID - Type UnspecifiedGROUP ID NUMBER