Provider Demographics
NPI:1972519932
Name:DAVIDOFF, JACK B (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:B
Last Name:DAVIDOFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 PALM PL
Mailing Address - Street 2:
Mailing Address - City:HAINES CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33844-5813
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2300 E COUNTY ROAD 540A
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-3825
Practice Address - Country:US
Practice Address - Phone:863-680-7190
Practice Address - Fax:866-264-8519
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME116103207Q00000X, 207Q00000X
NY191940207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY70000AOtherMEDICARE GROUP
NY70000AOtherMEDICARE GROUP