Provider Demographics
NPI:1538145636
Name:ERWIN, JACKLIEN T (MD)
Entity Type:Individual
Prefix:
First Name:JACKLIEN
Middle Name:T
Last Name:ERWIN
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 1:12843 US HWY 19
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34667
Mailing Address - Country:US
Mailing Address - Phone:727-863-5242
Mailing Address - Fax:727-868-0823
Practice Address - Street 1:12843 US HWY 19
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667
Practice Address - Country:US
Practice Address - Phone:727-863-5242
Practice Address - Fax:727-868-0823
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0041218207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
51206Medicare ID - Type Unspecified
D85915Medicare UPIN