Healthcare Provider Details

I. General information

NPI: 1386711166
Provider Name (Legal Business Name): JEFFREY MICHAEL HARTOG JEFFREY HARTOG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4355 BEAR GULLY RD
WINTER PARK FL
32792-9422
US

IV. Provider business mailing address

4355 BEAR GULLY RD
WINTER PARK FL
32792-9422
US

V. Phone/Fax

Practice location:
  • Phone: 407-678-3116
  • Fax: 321-282-0565
Mailing address:
  • Phone: 407-678-3116
  • Fax: 321-282-0565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberME64197
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: