Provider Demographics
NPI:1811186653
Name:JEFFREY S GORODETSKY MD PA
Entity Type:Organization
Organization Name:JEFFREY S GORODETSKY MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:GORODETSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-223-4504
Mailing Address - Street 1:433 E OCEAN BLVD
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-2573
Mailing Address - Country:US
Mailing Address - Phone:772-223-4504
Mailing Address - Fax:772-223-5988
Practice Address - Street 1:433 E OCEAN BLVD
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2573
Practice Address - Country:US
Practice Address - Phone:772-223-4504
Practice Address - Fax:772-223-5988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0053894173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL07463OtherBLUE CROSS BLUE SHIELD
FLP00307631OtherRAILROAD MEDICARE
FL048745701Medicaid
FL07463POtherMEDICARE INDIVIDUAL
FLK9632OtherMEDICACE GROUP
FLK9632OtherMEDICACE GROUP
FLP00307631OtherRAILROAD MEDICARE