Provider Demographics
NPI:1396817557
Name:EJERCITO, BELLA CAIMOL (ME 22078)
Entity Type:Individual
Prefix:DR
First Name:BELLA
Middle Name:CAIMOL
Last Name:EJERCITO
Suffix:
Gender:F
Credentials:ME 22078
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4608 NORWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32206
Mailing Address - Country:US
Mailing Address - Phone:904-764-6161
Mailing Address - Fax:904-764-2227
Practice Address - Street 1:4608 NORWOOD AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32206
Practice Address - Country:US
Practice Address - Phone:904-764-6161
Practice Address - Fax:904-764-2227
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME22078207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D53127Medicare UPIN
00016987Medicare ID - Type Unspecified