Provider Demographics
NPI:1962607416
Name:JAFFRAY PODIATRY CENTER PL LLC
Entity type:Organization
Organization Name:JAFFRAY PODIATRY CENTER PL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:JAFFRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:813-949-7555
Mailing Address - Street 1:PO BOX 340683
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33694-0683
Mailing Address - Country:US
Mailing Address - Phone:813-949-7555
Mailing Address - Fax:813-949-7554
Practice Address - Street 1:18940 DALE MABRY HWY N
Practice Address - Street 2:SUITE 101
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33548-4906
Practice Address - Country:US
Practice Address - Phone:813-949-7555
Practice Address - Fax:813-949-7554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-15
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP02662213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL390467900Medicaid
FL4502420001Medicare NSC
FLK3691Medicare PIN
FL390467900Medicaid