Provider Demographics
NPI:1639160831
Name:AZELVANDRE, JACQUELINE (DO)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:AZELVANDRE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 S MILWEE ST
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-4127
Mailing Address - Country:US
Mailing Address - Phone:407-339-1060
Mailing Address - Fax:407-339-1081
Practice Address - Street 1:301 S MILWEE ST
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-4127
Practice Address - Country:US
Practice Address - Phone:407-339-1060
Practice Address - Fax:407-339-1081
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-04
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS4390207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL82456ZMedicare PIN
FLE34849Medicare UPIN