Provider Demographics
NPI:1346494556
Name:PETER C. JANSEN MD
Entity Type:Organization
Organization Name:PETER C. JANSEN MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:C
Authorized Official - Last Name:JANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-259-7815
Mailing Address - Street 1:PO BOX 8879
Mailing Address - Street 2:
Mailing Address - City:FLEMMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32006-0019
Mailing Address - Country:US
Mailing Address - Phone:904-259-7815
Mailing Address - Fax:904-259-4675
Practice Address - Street 1:159 N 3RD ST
Practice Address - Street 2:
Practice Address - City:MACCLENNY
Practice Address - State:FL
Practice Address - Zip Code:32063-2103
Practice Address - Country:US
Practice Address - Phone:904-259-7815
Practice Address - Fax:904-259-4675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-14
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0069804207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty