Provider Demographics
NPI:1740200864
Name:GEWOLB, JAY D (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:D
Last Name:GEWOLB
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 1:500 WINDERLEY PL STE 115
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7406
Mailing Address - Country:US
Mailing Address - Phone:407-581-9180
Mailing Address - Fax:865-560-7066
Practice Address - Street 1:500 WINDERLEY PL STE 115
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-7406
Practice Address - Country:US
Practice Address - Phone:407-581-9180
Practice Address - Fax:865-560-7066
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME55713207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
050066862OtherRAILROAD MEDICARE
XXX-XX-8006OtherCHAMPUS / TRICARE SOUTH REGION
FL09206OtherBCBS
FL0636517 00Medicaid
FL09206OtherBCBS
FL09206YMedicare PIN