Provider Demographics
NPI:1114601192
Name:CARRILLO MOYA, JORGE LUIS (HSE)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:LUIS
Last Name:CARRILLO MOYA
Suffix:
Gender:M
Credentials:HSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 NW 14TH ST BLDG SUITE505
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33125-1673
Mailing Address - Country:US
Mailing Address - Phone:305-243-6704
Mailing Address - Fax:305-243-6191
Practice Address - Street 1:1321 NW 14TH ST BLDG SUITE505
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-1673
Practice Address - Country:US
Practice Address - Phone:305-243-6704
Practice Address - Fax:305-243-6191
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHSE36492207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology