Provider Demographics
NPI:1578658258
Name:STOLZENBERG, JERRY (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:
Last Name:STOLZENBERG
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 1:10691 HAWKS VISTA ST
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-8211
Mailing Address - Country:US
Mailing Address - Phone:954-916-9188
Mailing Address - Fax:954-916-3656
Practice Address - Street 1:10691 HAWKS VISTA ST
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-8211
Practice Address - Country:US
Practice Address - Phone:954-916-9188
Practice Address - Fax:954-916-3656
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL147872085N0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL91092Medicare ID - Type UnspecifiedPROVIDER NUMBER