Healthcare Provider Details

I. General information

NPI: 1821559428
Provider Name (Legal Business Name): JEREMY JACKSON MAYFIELD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2019
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 W OAK ST STE 201
KISSIMMEE FL
34741-4998
US

IV. Provider business mailing address

720 W OAK ST STE 201
KISSIMMEE FL
34741-4998
US

V. Phone/Fax

Practice location:
  • Phone: 321-697-1730
  • Fax:
Mailing address:
  • Phone: 321-697-1730
  • Fax: 407-518-3923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberME151046
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: