Provider Demographics
NPI:1457390098
Name:JETT, GARY E (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:E
Last Name:JETT
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 1:619 NW 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136
Mailing Address - Country:US
Mailing Address - Phone:305-821-5119
Mailing Address - Fax:305-227-1684
Practice Address - Street 1:619 NW 12TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-3609
Practice Address - Country:US
Practice Address - Phone:305-821-5119
Practice Address - Fax:305-227-1684
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VI1084208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
VIB43059Medicare UPIN