Provider Demographics
NPI:1033318928
Name:LE-BERT, GEORGE GLENN (DO)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:GLENN
Last Name:LE-BERT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 43667
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32203-3667
Mailing Address - Country:US
Mailing Address - Phone:904-398-3760
Mailing Address - Fax:904-261-6567
Practice Address - Street 1:1340 S 18TH ST STE 202
Practice Address - Street 2:CREDENTIALING DEPARTMENT
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-4733
Practice Address - Country:US
Practice Address - Phone:904-261-9786
Practice Address - Fax:904-261-6567
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS10063207RC0000X, 207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00944481OtherRAILROAD MEDICARE
FL000794000Medicaid
FLCG822WMedicare PIN