Provider Demographics
NPI:1053494567
Name:TRAVIESO, JOSE A (CPHT)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:A
Last Name:TRAVIESO
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12327 NW 7TH LN
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33182-2019
Mailing Address - Country:US
Mailing Address - Phone:305-297-8623
Mailing Address - Fax:
Practice Address - Street 1:2600 W FLAGLER ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33135-1425
Practice Address - Country:US
Practice Address - Phone:305-644-7569
Practice Address - Fax:305-644-3074
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1701-0086-0609-374183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician