Provider Demographics
NPI:1346299104
Name:YATACO, JOSE C (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:C
Last Name:YATACO
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 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:904-450-6063
Mailing Address - Fax:904-450-6401
Practice Address - Street 1:2 SHIRCLIFF WAY BLDG STE 435
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4753
Practice Address - Country:US
Practice Address - Phone:904-308-6900
Practice Address - Fax:904-308-6927
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN40977207RP1001X
FLME91430207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004504000Medicaid
FL004504000Medicaid