MEDICARE: DR. JEFFREY S GOTTFRIED D.O.

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	207Q00000X	Family Medicine Physician	OS7057	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

General Provider Information

NPI Number	:	1639255516
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY S GOTTFRIED D.O.

Provider Business Mailing Address
First Line	:	900 VIRGINIA AVE
Second Line	:	SUITE 10
City	:	FORT PIERCE
State	:	FL
Zip	:	34982-5882
Country	:	US
Telephone Number	:	772-464-6551
Fax Number	:	772-465-0322

Provider Business Practice Location Address
First Line	:	900 VIRGINIA AVE
Second Line	:	SUITE 10
City	:	FORT PIERCE
State	:	FL
Zip	:	34982-5882
Country	:	US
Telephone Number	:	772-464-6551
Fax Number	:	772-465-0322

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

Provider Enumeration Date	:	10/31/2006
Last Update Date	:	10/23/2007

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Directions to “ DR. JEFFREY S GOTTFRIED D.O.” Practice Location

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