Healthcare Provider Details

I. General information

NPI: 1710980982
Provider Name (Legal Business Name): MARK A JAFFE DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15050 W. TETHERCLIFT STREET
DAVIE FL
33331
US

IV. Provider business mailing address

15050 W. TETHERCLIFT STREET
DAVIE FL
33331
US

V. Phone/Fax

Practice location:
  • Phone: 954-434-9070
  • Fax:
Mailing address:
  • Phone: 954-434-9070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberP0001444
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: