Provider Demographics
NPI:1689718694
Name:ISSAR, JEETENDRA (MD)
Entity Type:Individual
Prefix:
First Name:JEETENDRA
Middle Name:
Last Name:ISSAR
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 1:3810 S FLORIDA AVE
Mailing Address - Street 2:SUITE # A1
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-1105
Mailing Address - Country:US
Mailing Address - Phone:863-619-5100
Mailing Address - Fax:863-619-5102
Practice Address - Street 1:1429 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-3206
Practice Address - Country:US
Practice Address - Phone:863-687-0200
Practice Address - Fax:863-687-0222
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88343207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL266240000Medicaid
FLK4399Medicare ID - Type Unspecified
FLH08884Medicare UPIN