Provider Demographics
NPI:1154841450
Name:SEQUEIRA GROSS, JUAN CARLOS (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:SEQUEIRA GROSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 919771
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-9771
Mailing Address - Country:US
Mailing Address - Phone:239-278-3600
Mailing Address - Fax:239-226-4650
Practice Address - Street 1:2232 GRAND AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-3717
Practice Address - Country:US
Practice Address - Phone:239-344-2330
Practice Address - Fax:239-322-4701
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-27
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME143344207R00000X
261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMM359OtherMEDICARE
FL106548800Medicaid