Provider Demographics
NPI:1962410381
Name:MARK JAFFE M D P A
Entity type:Organization
Organization Name:MARK JAFFE M D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:JAFFE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-441-9995
Mailing Address - Street 1:1 SW 129TH AVE
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33027-1761
Mailing Address - Country:US
Mailing Address - Phone:954-441-9995
Mailing Address - Fax:954-441-9033
Practice Address - Street 1:1 SW 129TH AVE
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33027-1761
Practice Address - Country:US
Practice Address - Phone:954-441-9995
Practice Address - Fax:954-441-9033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0068879174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL379137800Medicaid
FLFR664AOtherMEDICARE PTAN
FLFR664AOtherMEDICARE PTAN
FLG22211Medicare UPIN
FL379137800Medicaid