Provider Demographics
NPI:1073817052
Name:JOSE F BACA MD INC
Entity Type:Organization
Organization Name:JOSE F BACA MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:F
Authorized Official - Last Name:BACA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-696-7557
Mailing Address - Street 1:777 E 25TH ST STE 509
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33013-3834
Mailing Address - Country:US
Mailing Address - Phone:305-696-7557
Mailing Address - Fax:305-696-7469
Practice Address - Street 1:777 E 25TH ST STE 509
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33013-3834
Practice Address - Country:US
Practice Address - Phone:305-696-7557
Practice Address - Fax:305-696-7469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-05
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME57517207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL371253200Medicaid
F41833Medicare UPIN