Provider Demographics
NPI:1003046962
Name:PANCRUDO, JACKLYN REYES (DO)
Entity Type:Individual
Prefix:
First Name:JACKLYN
Middle Name:REYES
Last Name:PANCRUDO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1875 NW CORPORATE BLVD
Mailing Address - Street 2:SUITE 270
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-8542
Mailing Address - Country:US
Mailing Address - Phone:561-997-0821
Mailing Address - Fax:
Practice Address - Street 1:11750 SW 40TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-3530
Practice Address - Country:US
Practice Address - Phone:561-997-0821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-24
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS11255207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine