Healthcare Provider Details

I. General information

NPI: 1164457412
Provider Name (Legal Business Name): JERRY LEO HEDRICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 11/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 VONDERBURG DRIVE STE 115W
BRANDON FL
33511-5969
US

IV. Provider business mailing address

4651 VAN DYKE RD
LUTZ FL
33558-4880
US

V. Phone/Fax

Practice location:
  • Phone: 813-685-0306
  • Fax: 813-651-1026
Mailing address:
  • Phone: 813-321-1786
  • Fax: 813-321-1787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME38730
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: