Healthcare Provider Details

I. General information

NPI: 1407853195
Provider Name (Legal Business Name): CITRUS GASTROENTEROLOGY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 06/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3653 E FOREST DR
INVERNESS FL
34453-0787
US

IV. Provider business mailing address

3653 E FOREST DR
INVERNESS FL
34453-0787
US

V. Phone/Fax

Practice location:
  • Phone: 352-344-8080
  • Fax: 352-344-0631
Mailing address:
  • Phone: 352-344-8080
  • Fax: 352-344-0631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number80110022812
License Number StateFL

VIII. Authorized Official

Name: JOHANNES MARTENSSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 352-344-8080