Provider Demographics
NPI:1053522839
Name:JUNGST, ELIZABETH (MD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:JUNGST
Suffix:
Gender:F
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:PO BOX 863407
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-3407
Mailing Address - Country:US
Mailing Address - Phone:941-917-2600
Mailing Address - Fax:941-917-7884
Practice Address - Street 1:1921 WALDEMERE ST
Practice Address - Street 2:SUITE 405
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2943
Practice Address - Country:US
Practice Address - Phone:941-917-3500
Practice Address - Fax:941-917-3501
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57010095207R00000X
FLME102753207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL76218OtherBCBS
FLBA554ZMedicare PIN