Provider Demographics
NPI:1639255516
Name:GOTTFRIED, JEFFREY S (DO)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:S
Last Name:GOTTFRIED
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 VIRGINIA AVE
Mailing Address - Street 2:SUITE 10
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-5882
Mailing Address - Country:US
Mailing Address - Phone:772-464-6551
Mailing Address - Fax:772-465-0322
Practice Address - Street 1:900 VIRGINIA AVE
Practice Address - Street 2:SUITE 10
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-5882
Practice Address - Country:US
Practice Address - Phone:772-464-6551
Practice Address - Fax:772-465-0322
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7057207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK4574Medicare ID - Type Unspecified
FLG88844Medicare UPIN