Healthcare Provider Details

I. General information

NPI: 1467497271
Provider Name (Legal Business Name): JERRY MARTIN ALSTOTT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 05/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8030 SAINT JAMES WAY
MOUNT DORA FL
32757-9134
US

IV. Provider business mailing address

8030 SAINT JAMES WAY
MOUNT DORA FL
32757-9134
US

V. Phone/Fax

Practice location:
  • Phone: 407-908-0064
  • Fax: 352-383-9319
Mailing address:
  • Phone: 407-908-0064
  • Fax: 352-383-9319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberME0037307
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberME0037307
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: