Provider Demographics
NPI:1558364265
Name:LEVENTHAL, JERRY (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:
Last Name:LEVENTHAL
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 1:21 HOSPITAL DR
Mailing Address - Street 2:STE 280
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-2452
Mailing Address - Country:US
Mailing Address - Phone:386-437-4711
Mailing Address - Fax:386-767-5580
Practice Address - Street 1:21 HOSPITAL DRIVE
Practice Address - Street 2:STE 280
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164
Practice Address - Country:US
Practice Address - Phone:386-437-4711
Practice Address - Fax:386-437-4772
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69470174400000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL277845900Medicaid
FL28165OtherBLUE CROSS BLUE SHIELD
FLG19131Medicare UPIN
FL28165UMedicare PIN
FL277845900Medicaid
FL28165YMedicare PIN