Provider Demographics
NPI:1801818703
Name:KROTENBERG, JEFFREY ALAN (DO)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ALAN
Last Name:KROTENBERG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 WAYMONT CT
Mailing Address - Street 2:SUITE 111
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-3566
Mailing Address - Country:US
Mailing Address - Phone:407-324-0405
Mailing Address - Fax:407-324-0075
Practice Address - Street 1:305 WAYMONT CT
Practice Address - Street 2:SUITE 111
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3566
Practice Address - Country:US
Practice Address - Phone:407-324-0405
Practice Address - Fax:407-324-0075
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS00049852084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL056251300Medicaid
FL19404OtherUNITED HEALTHCARE
FL121134400OtherDEPT OF LABOR
FL260017797OtherRAILROAD MEDICARE
FL80108OtherBLUE CROSS BLUE SHIELD
FL3196405002OtherGHI
FL066470OtherVALUE OPTIONS
FL056251300Medicaid
FL19404OtherUNITED HEALTHCARE