1043563513 NPI number — JESUS MONTESANO MD LLC

Table of content: (NPI 1043563513)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043563513 NPI number — JESUS MONTESANO MD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JESUS MONTESANO MD LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
JESUS MONTESANO MD PA
Provider Other Organization Name Type Code:
3
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:
1043563513
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 NW 57TH CT STE 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33126-3292
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-649-8100
Provider Business Mailing Address Fax Number:
305-835-0550

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
664 E 25TH ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
HIALEAH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33013-3805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-835-7625
Provider Business Practice Location Address Fax Number:
305-835-0550
Provider Enumeration Date:
10/22/2012

Additional Information

Authorized Official

Authorized Official Last Name:
DE VERA
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
N
Authorized Official Title or Position:
RA
Authorized Official Telephone Number:
786-200-8305

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  ME 57047 , 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: 064494300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com