Provider Demographics
NPI:1952042830
Name:WEST, JEREMY SCOTT
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:SCOTT
Last Name:WEST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 800
Mailing Address - Street 2:
Mailing Address - City:RAIFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32083-0800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23916 NW 83RD AVE
Practice Address - Street 2:
Practice Address - City:RAIFORD
Practice Address - State:FL
Practice Address - Zip Code:32083-1003
Practice Address - Country:US
Practice Address - Phone:904-368-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9115272208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice