Provider Demographics
NPI:1215928478
Name:PAONESSA, JEFFREY L (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:L
Last Name:PAONESSA
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 1:6112 KIPPS COLONY DR W
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33707-3970
Mailing Address - Country:US
Mailing Address - Phone:727-347-3610
Mailing Address - Fax:
Practice Address - Street 1:6112 KIPPS COLONY DR W
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:FL
Practice Address - Zip Code:33707-3970
Practice Address - Country:US
Practice Address - Phone:727-347-3610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-04
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME59292207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL055225900Medicaid
FL12173ZMedicare PIN
FL055225900Medicaid
FL12173XMedicare PIN
FL1168350001Medicare NSC