Healthcare Provider Details

I. General information

NPI: 1891929063
Provider Name (Legal Business Name): JEROLD NORMAN CHIP I MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2009
Last Update Date: 02/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 N FLORIDA AVE
LAKELAND FL
33801-4902
US

IV. Provider business mailing address

1395 NW 167TH ST
MIAMI GARDENS FL
33169-5742
US

V. Phone/Fax

Practice location:
  • Phone: 863-209-7003
  • Fax: 863-284-3083
Mailing address:
  • Phone: 305-831-4761
  • Fax: 305-831-4761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301094726
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number01019735A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME123575
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: