Provider Demographics
NPI:1811175326
Name:ROOT, JEFFREY ROBERT (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ROBERT
Last Name:ROOT
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 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:904-450-6063
Mailing Address - Fax:904-539-4092
Practice Address - Street 1:3871 E HIGHWAY 98 STE 200
Practice Address - Street 2:
Practice Address - City:PORT ST JOE
Practice Address - State:FL
Practice Address - Zip Code:32456-5302
Practice Address - Country:US
Practice Address - Phone:850-229-5833
Practice Address - Fax:850-229-5832
Is Sole Proprietor?:No
Enumeration Date:2008-02-06
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME159955208600000X
CAA95787208600000X
GA070902208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11952742OtherCAQH PROVIDER ID
CA11952742OtherCAQH PROVIDER ID
CAP00929316Medicare PIN