Provider Demographics
NPI:1710041231
Name:GERZENSHTEIN, JACOB (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:GERZENSHTEIN
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 1:4429 FLORIDA NATIONAL DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-1516
Mailing Address - Country:US
Mailing Address - Phone:863-647-2200
Mailing Address - Fax:888-854-1888
Practice Address - Street 1:4429 FLORIDA NATIONAL DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-1516
Practice Address - Country:US
Practice Address - Phone:863-647-2200
Practice Address - Fax:888-854-1888
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME957192082S0099X, 2082S0105X, 2083P0011X, 2086S0122X, 208200000X, 207PE0005X
WI479122086S0122X
IL036-1037172086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34677200Medicaid
WIWI2343001Medicare PIN
WI54176 0380Medicare PIN
WIWI2352001Medicare PIN
WI34677200Medicaid
1992094684Medicare NSC