Provider Demographics
NPI:1265547103
Name:GREENBLUM, JESSE SETH (MD)
Entity type:Individual
Prefix:DR
First Name:JESSE
Middle Name:SETH
Last Name:GREENBLUM
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 1:1411 S 14TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-3031
Mailing Address - Country:US
Mailing Address - Phone:904-261-5605
Mailing Address - Fax:904-277-0725
Practice Address - Street 1:1411 S 14TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-3031
Practice Address - Country:US
Practice Address - Phone:904-261-5605
Practice Address - Fax:904-277-0725
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME45241207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00395117AMedicaid
02586AMedicare ID - Type Unspecified
D50570Medicare UPIN