Provider Demographics
NPI:1720815079
Name:LOVESTRAND, JEREMIAH JAMES
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:JAMES
Last Name:LOVESTRAND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 E DAYBREAK LN
Mailing Address - Street 2:
Mailing Address - City:FLORAL CITY
Mailing Address - State:FL
Mailing Address - Zip Code:34436-5017
Mailing Address - Country:US
Mailing Address - Phone:352-400-9863
Mailing Address - Fax:
Practice Address - Street 1:9330 STATE ROAD 54
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-1808
Practice Address - Country:US
Practice Address - Phone:727-834-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-18
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist AssistantGroup - Single Specialty