Provider Demographics
NPI:1669468096
Name:JURBALA, BRIAN MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:MICHAEL
Last Name:JURBALA
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 1:2161 E COUNTY ROAD 540A
Mailing Address - Street 2:#286
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-3794
Mailing Address - Country:US
Mailing Address - Phone:863-398-0039
Mailing Address - Fax:863-709-1060
Practice Address - Street 1:3317 US HIGHWAY 98 S STE 9
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-8316
Practice Address - Country:US
Practice Address - Phone:863-709-8777
Practice Address - Fax:863-709-1060
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-21
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME70116207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020593810OtherGROUP # FOR TRICARE
FL264652800Medicaid
FL17404OtherBLUE CROSS BLUE SHIELD
FL200046088OtherRAILROAD MEDICARE
FL264652800OtherPROVIDER # FOR TRICARE
FL264652800Medicaid
FL264652800OtherPROVIDER # FOR TRICARE
FL5377960005Medicare NSC
FL020593810OtherGROUP # FOR TRICARE
FL17404ZMedicare ID - Type UnspecifiedINDIVIDUAL PROVIDER NUMBE
FL5377960004Medicare NSC