Provider Demographics
NPI:1558358382
Name:MARGOLIN, JERRY ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:ALAN
Last Name:MARGOLIN
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 1:2818 SCOBEE DR
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683-7212
Mailing Address - Country:US
Mailing Address - Phone:727-736-4544
Mailing Address - Fax:
Practice Address - Street 1:501 S LINCOLN AVE
Practice Address - Street 2:SUITE 26
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-5945
Practice Address - Country:US
Practice Address - Phone:727-442-2193
Practice Address - Fax:727-466-6483
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17214207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
D58111Medicare UPIN
FL71551Medicare ID - Type Unspecified