Provider Demographics
NPI:1740397025
Name:GRZEBIELUCH, JERZY (MD)
Entity Type:Individual
Prefix:DR
First Name:JERZY
Middle Name:
Last Name:GRZEBIELUCH
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 1:4 2ND ST SE
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-5502
Mailing Address - Country:US
Mailing Address - Phone:850-864-2008
Mailing Address - Fax:850-864-5008
Practice Address - Street 1:4 2ND ST SE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-5502
Practice Address - Country:US
Practice Address - Phone:850-864-2008
Practice Address - Fax:850-864-5008
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME827842084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL53114OtherSPECIALITY LICENSE
FL13115OtherBCBS OF FLORIDA
FLME 82784OtherFLORIDA LICENSE
FLME 82784OtherFLORIDA LICENSE
FL53114OtherSPECIALITY LICENSE
FL13115Medicare ID - Type UnspecifiedMEDICARE