Provider Demographics
NPI:1114016052
Name:FICHERA MACALUSO, JENNIFER L (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:FICHERA MACALUSO
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 1:3241 EXECUTIVE WAY
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-3931
Mailing Address - Country:US
Mailing Address - Phone:954-985-6500
Mailing Address - Fax:954-967-8419
Practice Address - Street 1:700 N HIATUS RD
Practice Address - Street 2:SUITE 105
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026
Practice Address - Country:US
Practice Address - Phone:954-433-4744
Practice Address - Fax:954-433-4635
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9786207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL278488200Medicaid
FL278488200Medicaid