Provider Demographics
NPI:1578560835
Name:BERTOZZI, GIANCARLO (MD)
Entity Type:Individual
Prefix:DR
First Name:GIANCARLO
Middle Name:
Last Name:BERTOZZI
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 1:3599 UNIVERSITY BLVD S
Mailing Address - Street 2:SUITE 802
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4252
Mailing Address - Country:US
Mailing Address - Phone:904-396-2421
Mailing Address - Fax:904-398-1854
Practice Address - Street 1:3599 UNIVERSITY BLVD S
Practice Address - Street 2:SUITE 802
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4252
Practice Address - Country:US
Practice Address - Phone:904-396-2421
Practice Address - Fax:904-398-1854
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-01
Last Update Date:2008-02-22
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
FLME0020514208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL16933OtherBLUE CROSS BLUE SHIELD
FL207738OtherAVMED
3690OtherUNIVERSAL HEALTHCARE
FL4009642-002OtherCIGNA
4081875OtherAETNA
310091OtherHEALTHEASE
310091OtherWELLCARE
P00013539OtherRAILROAD MEDICARE
4081875OtherAETNA
FLD67142Medicare UPIN