Provider Demographics
NPI:1285043901
Name:CORREA-LASANTA, JESMARIE (MD)
Entity Type:Individual
Prefix:
First Name:JESMARIE
Middle Name:
Last Name:CORREA-LASANTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JESMARIE
Other - Middle Name:
Other - Last Name:CORREA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-361-5630
Mailing Address - Fax:321-676-6434
Practice Address - Street 1:1350 HICKORY ST STE 101
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3224
Practice Address - Country:US
Practice Address - Phone:321-361-5670
Practice Address - Fax:321-676-6434
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-06
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME131933207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLNS400OtherMEDICARE HF
FL104224100Medicaid