Healthcare Provider Details

I. General information

NPI: 1740397025
Provider Name (Legal Business Name): JERZY GRZEBIELUCH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 2ND ST SE
FORT WALTON BEACH FL
32548-5502
US

IV. Provider business mailing address

4 2ND ST SE
FORT WALTON BEACH FL
32548-5502
US

V. Phone/Fax

Practice location:
  • Phone: 850-864-2008
  • Fax: 850-864-5008
Mailing address:
  • Phone: 850-864-2008
  • Fax: 850-864-5008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME82784
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberME82784
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: