Provider Demographics
NPI:1376519553
Name:PUELL, JOSE DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:DAVID
Last Name:PUELL
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 1:1454 MADISON AVE W
Mailing Address - Street 2:
Mailing Address - City:IMMOKALEE
Mailing Address - State:FL
Mailing Address - Zip Code:34142-2200
Mailing Address - Country:US
Mailing Address - Phone:239-658-3064
Mailing Address - Fax:239-658-3175
Practice Address - Street 1:6350 DAVIS BLVD # 1001
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34104-5323
Practice Address - Country:US
Practice Address - Phone:239-658-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME111013207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004105900OtherFLORIDA MEDICAID
FL2-1547OtherMEDICARE
FL2-1547OtherMEDICARE