Provider Demographics
NPI:1336105683
Name:PICO, JOSE (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:PICO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 SE HILLMOOR DR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7539
Mailing Address - Country:US
Mailing Address - Phone:772-398-7936
Mailing Address - Fax:772-398-7970
Practice Address - Street 1:1700 SE HILLMOOR DR
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7539
Practice Address - Country:US
Practice Address - Phone:772-398-7936
Practice Address - Fax:772-398-7970
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME68578207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL273519900Medicaid
FL27713Medicare UPIN
FL273519900Medicaid