Provider Demographics
NPI:1467400655
Name:RONCANCIO, JAIME R (DO)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:R
Last Name:RONCANCIO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 863481
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-3481
Mailing Address - Country:US
Mailing Address - Phone:800-514-1494
Mailing Address - Fax:904-805-1302
Practice Address - Street 1:2500 SW 75TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-2805
Practice Address - Country:US
Practice Address - Phone:305-264-5252
Practice Address - Fax:800-536-8431
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0007634207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL49699OtherBCBS
FLP00367253OtherRR MCR
FL258231700Medicaid
FL49699RMedicare PIN
FL258231700Medicaid
FLG72248Medicare UPIN