Healthcare Provider Details

I. General information

NPI: 1033520812
Provider Name (Legal Business Name): JEAN-EDSON BELCOURT M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2014
Last Update Date: 11/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

449 W 23RD ST
PANAMA CITY FL
32405-4507
US

IV. Provider business mailing address

449 W 23RD ST
PANAMA CITY FL
32405-4507
US

V. Phone/Fax

Practice location:
  • Phone: 850-767-2100
  • Fax: 850-769-8341
Mailing address:
  • Phone: 850-767-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number291178-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME131900
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: