Provider Demographics
NPI:1952440372
Name:PELLETIER, JESSE SHANE (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:SHANE
Last Name:PELLETIER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1400 NE MIAMI GARDENS DR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33179-4845
Mailing Address - Country:US
Mailing Address - Phone:305-940-1500
Mailing Address - Fax:305-940-1501
Practice Address - Street 1:1400 NE MIAMI GARDENS DR
Practice Address - Street 2:SUITE 203
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33179-4845
Practice Address - Country:US
Practice Address - Phone:305-940-1500
Practice Address - Fax:305-940-1501
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME99313207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL279056400Medicaid
FL279056400Medicaid