Healthcare Provider Details

I. General information

NPI: 1811186653
Provider Name (Legal Business Name): JEFFREY S GORODETSKY MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2007
Last Update Date: 09/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 E OCEAN BLVD
STUART FL
34994-2573
US

IV. Provider business mailing address

433 E OCEAN BLVD
STUART FL
34994-2573
US

V. Phone/Fax

Practice location:
  • Phone: 772-223-4504
  • Fax: 772-223-5988
Mailing address:
  • Phone: 772-223-4504
  • Fax: 772-223-5988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberME0053894
License Number StateFL

VIII. Authorized Official

Name: DR. JEFFREY S GORODETSKY
Title or Position: PRESIDENT
Credential: MD
Phone: 772-223-4504