Provider Demographics
NPI:1376077719
Name:BURLISON, JUBETH CARLENE
Entity Type:Individual
Prefix:
First Name:JUBETH
Middle Name:CARLENE
Last Name:BURLISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8000 RED BUG LAKE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-9265
Mailing Address - Country:US
Mailing Address - Phone:407-366-6004
Mailing Address - Fax:407-366-6919
Practice Address - Street 1:8000 RED BUG LAKE RD STE 200
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-9265
Practice Address - Country:US
Practice Address - Phone:407-366-6004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-12
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLB642423896900390200000X
FLOS16163207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program