Provider Demographics
NPI:1043665169
Name:JETER, JUSTIN PARKER (MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:PARKER
Last Name:JETER
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 1:900 S PINE ISLAND RD STE 800
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-3923
Mailing Address - Country:US
Mailing Address - Phone:305-821-8611
Mailing Address - Fax:305-827-1753
Practice Address - Street 1:15507 NW 67TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-2108
Practice Address - Country:US
Practice Address - Phone:305-821-8611
Practice Address - Fax:305-827-1753
Is Sole Proprietor?:No
Enumeration Date:2016-04-26
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME140375208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103107800Medicaid