Provider Demographics
NPI:1730171075
Name:NEITLICH, JEFFREY D (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:D
Last Name:NEITLICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 ALTON RD
Mailing Address - Street 2:ASCHER BLDG, 2ND FLOOR
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33140-2800
Mailing Address - Country:US
Mailing Address - Phone:305-674-3977
Mailing Address - Fax:305-535-7919
Practice Address - Street 1:4300 ALTON RD
Practice Address - Street 2:ASCHER BLDG, 2ND FLOOR
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33140
Practice Address - Country:US
Practice Address - Phone:305-674-3977
Practice Address - Fax:305-535-7919
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0334002085R0202X
GA0646162085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001334002Medicaid
F89798Medicare UPIN
CT300002137Medicare ID - Type Unspecified