Provider Demographics
NPI:1437158870
Name:INFANTE, JORGE LUIS (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:LUIS
Last Name:INFANTE
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 1:4504 MOORE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-5220
Mailing Address - Country:US
Mailing Address - Phone:843-663-1043
Mailing Address - Fax:
Practice Address - Street 1:300 SINGLETON RIDGE RD
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-9142
Practice Address - Country:US
Practice Address - Phone:843-347-8015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27835207PE0004X
FLME129975207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC278354Medicaid
SC400685Medicaid
SCGP1426Medicaid
SCAA09135373Medicare PIN
SC400685Medicaid
SCGP1426Medicaid
SC278354Medicaid