Healthcare Provider Details

I. General information

NPI: 1033155171
Provider Name (Legal Business Name): JACK MARSHALL TRAINOR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 N FEDERAL HWY SUITE A-39
FT LAUDERDALE FL
33308-4608
US

IV. Provider business mailing address

2829 NE 33RD CT #405
FT LAUDERDALE FL
33306-2028
US

V. Phone/Fax

Practice location:
  • Phone: 954-771-8177
  • Fax: 954-771-3629
Mailing address:
  • Phone: 954-564-5725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberME77382
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: