Provider Demographics
NPI:1467554618
Name:CROOMS, JEFFREY WYATT (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:WYATT
Last Name:CROOMS
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 1:1405 CENTERVILLE RD
Mailing Address - Street 2:SUITE 4400
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4655
Mailing Address - Country:US
Mailing Address - Phone:850-877-6212
Mailing Address - Fax:850-878-4034
Practice Address - Street 1:1405 CENTERVILLE RD
Practice Address - Street 2:SUITE 4400
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4655
Practice Address - Country:US
Practice Address - Phone:850-877-6212
Practice Address - Fax:850-878-4034
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0043049208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0402681-00Medicaid
FL14132Medicare ID - Type Unspecified
FL0402681-00Medicaid