Basic Information
| Provider Information | |||||||||
| NPI: | 1669421889 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JEPMA | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 161 N CAUSEWAY | ||||||||
| Address2: | |||||||||
| City: | NEW SMYRNA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321695303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3864241584 | ||||||||
| FaxNumber: | 3864104800 | ||||||||
| Practice Location | |||||||||
| Address1: | 161 N CAUSEWAY | ||||||||
| Address2: | |||||||||
| City: | NEW SMYRNA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321695303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3864241584 | ||||||||
| FaxNumber: | 3864104800 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2006 | ||||||||
| LastUpdateDate: | 02/15/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 222975 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00354316 | 05 | NY | MEDICAID |