Basic Information
| Provider Information | |||||||||
| NPI: | 1063669125 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | JERALYN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 38135 MARKET SQ | ||||||||
| Address2: | |||||||||
| City: | ZEPHYRHILLS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335427505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8137802155 | ||||||||
| FaxNumber: | 8133555017 | ||||||||
| Practice Location | |||||||||
| Address1: | 38135 MARKET SQ | ||||||||
| Address2: | |||||||||
| City: | ZEPHYRHILLS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335427505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8137802155 | ||||||||
| FaxNumber: | 8133555017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2008 | ||||||||
| LastUpdateDate: | 06/26/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RS0010X | 99048726A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Sports Medicine | 208M00000X | ME120500 | FL | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | VAD000 | 01 | TN | FEDERAL UPIN | OTHER |