Provider Demographics
NPI:1417313750
Name:MALDONADO, JESSE JAMES
Entity Type:Individual
Prefix:
First Name:JESSE JAMES
Middle Name:
Last Name:MALDONADO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CARLOS G PARKER BLVD
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:TX
Mailing Address - Zip Code:76574
Mailing Address - Country:US
Mailing Address - Phone:512-352-2024
Mailing Address - Fax:
Practice Address - Street 1:100 CARLOS G PARKER BLVD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:TX
Practice Address - Zip Code:76574
Practice Address - Country:US
Practice Address - Phone:512-352-2024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-31
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX51691183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist