Provider Demographics
NPI:1275518391
Name:BROMBERG, JORDAN M (MD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:M
Last Name:BROMBERG
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:PO BOX 417
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-0417
Mailing Address - Country:US
Mailing Address - Phone:772-223-5665
Mailing Address - Fax:772-223-5646
Practice Address - Street 1:1095 NW SAINT LUCIE WEST BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1719
Practice Address - Country:US
Practice Address - Phone:772-223-5665
Practice Address - Fax:772-223-5646
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0045084207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL056427300Medicaid
FL05742Medicare PIN
FLD51412Medicare UPIN