Provider Demographics
NPI:1407853195
Name:CITRUS GASTROENTEROLOGY PA
Entity Type:Organization
Organization Name:CITRUS GASTROENTEROLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHANNES
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTENSSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-344-8080
Mailing Address - Street 1:3653 E FOREST DR
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34453-0787
Mailing Address - Country:US
Mailing Address - Phone:352-344-8080
Mailing Address - Fax:352-344-0631
Practice Address - Street 1:3653 E FOREST DR
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34453-0787
Practice Address - Country:US
Practice Address - Phone:352-344-8080
Practice Address - Fax:352-344-0631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL80110022812207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA173547OtherBS OF PENNSYLVANIA
FL21861OtherBCBS OF FLORIDA
FL263450300Medicaid
FL2900981OtherUNITED HEALTH CARE
GACN7015OtherRAILROAD MEDICARE PIN
FL84959OtherUMWA
FL213279OtherHEALTHEASE
TN4002702OtherBCBS OF TENNESSEE
FL160659200OtherDEPT OF LABOR
NY2400710OtherGHI
PA173547OtherBS OF PENNSYLVANIA
PA173547OtherBS OF PENNSYLVANIA