Provider Demographics
NPI:1407806417
Name:PALACIOS, JORGE L (MD)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:L
Last Name:PALACIOS
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 1:5874 E SHEPHERD AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93619-9524
Mailing Address - Country:US
Mailing Address - Phone:559-930-1265
Mailing Address - Fax:
Practice Address - Street 1:400 W. MINERAL
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-6237
Practice Address - Country:US
Practice Address - Phone:559-624-2000
Practice Address - Fax:559-741-4896
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69353207L00000X, 207LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A693530OtherBS OF CA
CA00A693530Medicaid
CA050089642OtherRAILROAD MEDICARE
CA00A693532Medicare PIN
CA00A693531Medicare PIN
CA00A693530OtherBS OF CA
CA00A693534Medicare PIN
CA050089642OtherRAILROAD MEDICARE
CA00A693533Medicare PIN