Provider Demographics
NPI:1316041064
Name:CULTRERA, JENNIFER LYN (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYN
Last Name:CULTRERA
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:PO BOX 102222
Mailing Address - Street 2:ATTN: CREDENTIAL DEPT
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2222
Mailing Address - Country:US
Mailing Address - Phone:239-432-8331
Mailing Address - Fax:813-976-7895
Practice Address - Street 1:1400 N US HIGHWAY 441
Practice Address - Street 2:SUITE 540
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-8975
Practice Address - Country:US
Practice Address - Phone:352-753-9777
Practice Address - Fax:352-753-9781
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME104856207RH0000X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000971000Medicaid
FLBY571YMedicare PIN
FL21682JMedicare PIN