1861581852 NPI number — JOSE D CERON-FUENTES M.D.

Table of content: JOSE D CERON-FUENTES M.D. (NPI 1861581852)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861581852 NPI number — JOSE D CERON-FUENTES M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CERON-FUENTES
Provider First Name:
JOSE
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861581852
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/02/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 45278
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32232-5278
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-202-1032
Provider Business Mailing Address Fax Number:
904-376-4107

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
820 PRUDENTIAL DR STE 304
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32207-8205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-202-3860
Provider Business Practice Location Address Fax Number:
904-202-3846
Provider Enumeration Date:
10/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  ME95797 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: ME95797 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 277524700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 104654200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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