Provider Demographics
NPI:1184867202
Name:CEDENO, JEANNE-ELYSE GRAY (MD)
Entity Type:Individual
Prefix:DR
First Name:JEANNE-ELYSE
Middle Name:GRAY
Last Name:CEDENO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JEANNE
Other - Middle Name:ELYSE
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10041 PINES BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-6170
Mailing Address - Country:US
Mailing Address - Phone:754-273-6278
Mailing Address - Fax:954-374-6954
Practice Address - Street 1:10041 PINES BLVD STE A
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-6170
Practice Address - Country:US
Practice Address - Phone:754-273-6278
Practice Address - Fax:954-374-6954
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-20
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10030078207Q00000X
FLME 106978207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004106900Medicaid
12239368OtherCAQH
12239368OtherCAQH