Provider Demographics
NPI:1750353207
Name:SCUDERI, GAELYN ELIZABETH LEE (MD)
Entity type:Individual
Prefix:DR
First Name:GAELYN
Middle Name:ELIZABETH LEE
Last Name:SCUDERI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:GAELYN
Other - Middle Name:ELIZABETH LEE
Other - Last Name:EATON-SCUDERI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 44008
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:904-383-1024
Mailing Address - Fax:904-244-4946
Practice Address - Street 1:655 W. 8TH STREET
Practice Address - Street 2:UNIVERSITY OF FLORIDA DEPARTMENT OF RADIOLOGY
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209
Practice Address - Country:US
Practice Address - Phone:904-244-4225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME920042085R0202X, 2085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003129253AMedicaid
FL14N7AOtherBCBS
FL007197400Medicaid
FL007197400Medicaid