Healthcare Provider Details

I. General information

NPI: 1750540381
Provider Name (Legal Business Name): JEFFREY C WINER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2008
Last Update Date: 09/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 CHILDRENS WAY
JACKSONVILLE FL
32207-8426
US

IV. Provider business mailing address

PO BOX 191 PROVIDER ENROLLMENT
ROCKLAND DE
19732-0191
US

V. Phone/Fax

Practice location:
  • Phone: 904-697-3032
  • Fax: 904-697-3011
Mailing address:
  • Phone: 302-651-6212
  • Fax: 302-651-4945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberL-235943
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME124822
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD039463
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: