1396133450 NPI number — JOSE A DE JESUS MD PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396133450 NPI number — JOSE A DE JESUS MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOSE A DE JESUS MD PA
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:
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:
1396133450
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/25/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9668
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PENSACOLA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32513-9668
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-478-1312
Provider Business Mailing Address Fax Number:
850-474-9060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1620 S CONGRESS AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
PALM SPRINGS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33461-2128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-561-2032
Provider Business Practice Location Address Fax Number:
561-968-1046
Provider Enumeration Date:
12/24/2014

Additional Information

Authorized Official

Authorized Official Last Name:
DE JESUS-CARBUCCIA
Authorized Official First Name:
JOSE
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
561-236-7741

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 008LM . This is a "FLORIDA BLUE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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