Healthcare Provider Details

I. General information

NPI: 1588749618
Provider Name (Legal Business Name): SOUTHWEST FLORIDA FERTILITY CENTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 01/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15730 NEW HAMPSHIRE CT SUITE 101
FORT MYERS FL
33908
US

IV. Provider business mailing address

15730 NEW HAMPSHIRE CT SUITE 101
FORT MYERS FL
33908
US

V. Phone/Fax

Practice location:
  • Phone: 239-561-3430
  • Fax: 239-561-6980
Mailing address:
  • Phone: 239-561-3430
  • Fax: 239-561-6980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License NumberME0057264
License Number StateFL

VIII. Authorized Official

Name: MR. JACOB LEON GLOCK
Title or Position: PRESIDENT
Credential: MEDICAL DOCTOR MD
Phone: 239-561-3430