Provider Demographics
NPI:1114948874
Name:DE JESUS, JOSE MIGUEL (MD, OD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:MIGUEL
Last Name:DE JESUS
Suffix:
Gender:M
Credentials:MD, OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:273 SIERRA MORENA
Mailing Address - Street 2:181 PB LA CUMBRE
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-0001
Mailing Address - Country:US
Mailing Address - Phone:787-905-3772
Mailing Address - Fax:787-705-5838
Practice Address - Street 1:1341 CALLE ALDEA APT TH1
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00907-2320
Practice Address - Country:US
Practice Address - Phone:787-905-3772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR194152W00000X
PR21104207P00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No152W00000XEye and Vision Services ProvidersOptometrist
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine