Provider Demographics
NPI:1114918968
Name:GERKOVICH, JACK H (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:H
Last Name:GERKOVICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:867 OUTER RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32814-6652
Mailing Address - Country:US
Mailing Address - Phone:407-898-6588
Mailing Address - Fax:407-245-1328
Practice Address - Street 1:867 OUTER RD
Practice Address - Street 2:SUITE A
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32814-6652
Practice Address - Country:US
Practice Address - Phone:407-898-6588
Practice Address - Fax:407-245-1328
Is Sole Proprietor?:No
Enumeration Date:2005-11-01
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME47289207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL046182200Medicaid
D20943Medicare UPIN
FL046182200Medicaid
FL04551XMedicare PIN