Provider Demographics
NPI:1942386230
Name:MCRAE, JESSE PITTMAN (MD)
Entity type:Individual
Prefix:DR
First Name:JESSE
Middle Name:PITTMAN
Last Name:MCRAE
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 1:1727 BLANDING BLVD
Mailing Address - Street 2:SUITE #101
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-1962
Mailing Address - Country:US
Mailing Address - Phone:904-384-3711
Mailing Address - Fax:
Practice Address - Street 1:1727 BLANDING BLVD
Practice Address - Street 2:SUITE #101
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-1962
Practice Address - Country:US
Practice Address - Phone:904-384-3711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL39207174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD52798Medicare UPIN
15954Medicare ID - Type Unspecified