Provider Demographics
NPI:1992902787
Name:SUTKOWI, JEANETTE A (DO)
Entity type:Individual
Prefix:DR
First Name:JEANETTE
Middle Name:A
Last Name:SUTKOWI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2445 LANE PARK RD
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-9648
Mailing Address - Country:US
Mailing Address - Phone:352-343-1341
Mailing Address - Fax:866-303-1184
Practice Address - Street 1:9400 TURKEY LAKE RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-8001
Practice Address - Country:US
Practice Address - Phone:321-384-5500
Practice Address - Fax:321-384-5550
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101017456207R00000X
FLOS10865207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002455800Medicaid
FLDM122YMedicare PIN