Healthcare Provider Details

I. General information

NPI: 1699744565
Provider Name (Legal Business Name): JAY SOURBEER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 04/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 BULLFINCH ROAD NAVY EXPERIMENTAL DIVING UNIT
PANAMA CITY FL
32407-7015
US

IV. Provider business mailing address

321 BULLFINCH ROAD NAVY EXPERIMENTAL DIVING UNIT
PANAMA CITY FL
32407-7015
US

V. Phone/Fax

Practice location:
  • Phone: 850-230-3148
  • Fax:
Mailing address:
  • Phone: 850-230-3148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberME58815
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: