Provider Demographics
NPI:1487600250
Name:EMMANUEL, GERRY F (MD)
Entity type:Individual
Prefix:
First Name:GERRY
Middle Name:F
Last Name:EMMANUEL
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 1:340 GARDEN LN
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32233-4522
Mailing Address - Country:US
Mailing Address - Phone:209-417-7666
Mailing Address - Fax:
Practice Address - Street 1:225 E ROBINSON ST
Practice Address - Street 2:SUITE 130
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32801-4322
Practice Address - Country:US
Practice Address - Phone:407-581-9180
Practice Address - Fax:865-560-7066
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC38755207L00000X
FLME113870207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C387550Medicaid
CA00C387550Medicaid
CABF627ZMedicare PIN
CA00C387552Medicare PIN
CA00C387551Medicare PIN
B50714Medicare UPIN
CACA146396Medicare PIN