Provider Demographics
NPI:1720757214
Name:MIEDEMA, JEFFREY B (MBA, RRT)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:B
Last Name:MIEDEMA
Suffix:
Gender:
Credentials:MBA, RRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 SW BENJAMIN PL
Mailing Address - Street 2:
Mailing Address - City:FORT WHITE
Mailing Address - State:FL
Mailing Address - Zip Code:32038-3003
Mailing Address - Country:US
Mailing Address - Phone:352-451-7453
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-265-0111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-08
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRT109212279P4000X, 2279C0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2279C0205XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredCritical Care
No2279P4000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredPatient Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000000000OtherN/A