Provider Demographics
NPI:1760464564
Name:GIERBOLINI, JOSE R (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:R
Last Name:GIERBOLINI
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 1:401 VENTURE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:SOUTH DAYTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32119-3478
Mailing Address - Country:US
Mailing Address - Phone:386-761-8888
Mailing Address - Fax:
Practice Address - Street 1:401 VENTURE DR
Practice Address - Street 2:
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-3478
Practice Address - Country:US
Practice Address - Phone:386-761-8888
Practice Address - Fax:386-760-8799
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0048493207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL04494400Medicaid
FL04494400Medicaid
FL53842Medicare ID - Type Unspecified