Healthcare Provider Details

I. General information

NPI: 1114849981
Provider Name (Legal Business Name): JONATHAN TRIDEV JEWRAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9400 TURKEY LAKE RD
ORLANDO FL
32819-8001
US

IV. Provider business mailing address

109 TEAKWOOD DR 109 TEAKWOOD DRIVE
KISSIMMEE FL
34743-8123
US

V. Phone/Fax

Practice location:
  • Phone: 407-351-8500
  • Fax:
Mailing address:
  • Phone: 407-750-1659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11049476
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: