Provider Demographics
NPI:1255309704
Name:MEMBRENO, JAIME HUMBERTO (MD)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:HUMBERTO
Last Name:MEMBRENO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:100 PARK PLACE BLVD
Mailing Address - Street 2:STE#202
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-2332
Mailing Address - Country:US
Mailing Address - Phone:407-931-1510
Mailing Address - Fax:407-931-3759
Practice Address - Street 1:100 PARK PLACE BLVD
Practice Address - Street 2:STE#202
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-2332
Practice Address - Country:US
Practice Address - Phone:407-931-1510
Practice Address - Fax:407-931-3759
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-10
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85244207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
U2626XMedicare PIN
FLU2626XMedicare PIN
H65829Medicare UPIN