Healthcare Provider Details

I. General information

NPI: 1013083997
Provider Name (Legal Business Name): JEREMY A DZEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 03/25/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23450 VIA COCONUT PT
ESTERO FL
34135-1877
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-468-0150
  • Fax: 239-343-4056
Mailing address:
  • Phone: 239-468-0150
  • Fax: 239-343-4056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number9243
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: