Provider Demographics
NPI:1023544012
Name:HALL, JAIME MARIE REALSEN (MD)
Entity type:Individual
Prefix:DR
First Name:JAIME
Middle Name:MARIE REALSEN
Last Name:HALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JAIME
Other - Middle Name:MARIE
Other - Last Name:REALSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-1100
Mailing Address - Fax:239-343-1101
Practice Address - Street 1:13782 PLANTATION RD STE 201
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4462
Practice Address - Country:US
Practice Address - Phone:239-343-1100
Practice Address - Fax:239-343-1101
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME142894207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104838200Medicaid