Healthcare Provider Details

I. General information

NPI: 1215924154
Provider Name (Legal Business Name): JONATHAN S DAITCH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 06/06/2024
Certification Date: 06/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8255 COLLEGE PKWY STE 100
FORT MYERS FL
33919-5119
US

IV. Provider business mailing address

PO BOX 07400
FORT MYERS FL
33919-0391
US

V. Phone/Fax

Practice location:
  • Phone: 239-437-8000
  • Fax: 239-437-9991
Mailing address:
  • Phone: 239-437-8000
  • Fax: 239-437-9991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberME60798
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: