Healthcare Provider Details

I. General information

NPI: 1548758857
Provider Name (Legal Business Name): JENAKAN JERAMIAN DEV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2018
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 W COCOA BEACH CSWY
COCOA BEACH FL
32931-3585
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 321-434-1771
  • Fax:
Mailing address:
  • Phone: 321-868-5871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME150433
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: