Healthcare Provider Details

I. General information

NPI: 1427049105
Provider Name (Legal Business Name): JEAN-CLAUDE JEANTY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 08/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 W GRANADA BLVD SUITE 3A
ORMOND BEACH FL
32174-8259
US

IV. Provider business mailing address

1275 W GRANADA BLVD SUITE 3A
ORMOND BEACH FL
32174-8259
US

V. Phone/Fax

Practice location:
  • Phone: 386-672-1490
  • Fax: 386-672-1682
Mailing address:
  • Phone: 386-672-1490
  • Fax: 386-672-1682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME0066990
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: