Healthcare Provider Details

I. General information

NPI: 1720044886
Provider Name (Legal Business Name): STANLEY JEW GWOCK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 05/20/2021
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2140 CENTERVILLE PL
TALLAHASSEE FL
32308-4342
US

IV. Provider business mailing address

PO BOX 15349
TALLAHASSEE FL
32317-5349
US

V. Phone/Fax

Practice location:
  • Phone: 850-383-3430
  • Fax:
Mailing address:
  • Phone: 850-383-3430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME 38724
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: