Provider Demographics
NPI:1932282753
Name:FLUD, JACQUELINE KELLY (DO)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:KELLY
Last Name:FLUD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3195 CITRUS TOWER BLVD
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711
Mailing Address - Country:US
Mailing Address - Phone:352-241-9700
Mailing Address - Fax:352-241-9784
Practice Address - Street 1:3195 CITRUS TOWER BLVD
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711
Practice Address - Country:US
Practice Address - Phone:352-247-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 9523207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2738287 00Medicaid
FL2738287 00Medicaid
FLU5033ZMedicare ID - Type UnspecifiedPHYSICIAN