Provider Demographics
NPI:1083279897
Name:OVIEDO, JOSE ANTONIO
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ANTONIO
Last Name:OVIEDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8811 FONTAINEBLEAU BLVD APT 411
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33172-4471
Mailing Address - Country:US
Mailing Address - Phone:786-539-7026
Mailing Address - Fax:
Practice Address - Street 1:12700 SW 122ND AVE STE 110
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-5271
Practice Address - Country:US
Practice Address - Phone:786-353-2900
Practice Address - Fax:786-364-1676
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-07
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-77205106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician