Provider Demographics
NPI:1013083997
Name:DZEN, JEREMY A (DO)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:A
Last Name:DZEN
Suffix:
Gender:M
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-468-0150
Mailing Address - Fax:239-343-4056
Practice Address - Street 1:23450 VIA COCONUT PT
Practice Address - Street 2:
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:34135-1877
Practice Address - Country:US
Practice Address - Phone:239-468-0150
Practice Address - Fax:239-343-4056
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH9243207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH40007221Medicaid
FL103653900Medicaid