MEDICARE: DR. JERRY LEVENTHAL M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	ME69470	FL
2	207Q00000X	Family Medicine Physician	ME69470	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	28165	OTHER	FL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1558364265
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JERRY LEVENTHAL M.D.

Provider Business Mailing Address
First Line	:	21 HOSPITAL DR
Second Line	:	STE 280
City	:	PALM COAST
State	:	FL
Zip	:	32164-2452
Country	:	US
Telephone Number	:	386-437-4711
Fax Number	:	386-767-5580

Provider Business Practice Location Address
First Line	:	21 HOSPITAL DRIVE
Second Line	:	STE 280
City	:	PALM COAST
State	:	FL
Zip	:	32164
Country	:	US
Telephone Number	:	386-437-4711
Fax Number	:	386-437-4772

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	04/12/2021

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