Provider Demographics
NPI:1497100143
Name:PALACIOS, JUAN JOSE (MD)
Entity Type:Individual
Prefix:MR
First Name:JUAN
Middle Name:JOSE
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 1:1611 NW 12 AVENUE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136
Mailing Address - Country:US
Mailing Address - Phone:305-585-5437
Mailing Address - Fax:
Practice Address - Street 1:6431 FANNIN ST STE MSB 3228
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-1501
Practice Address - Country:US
Practice Address - Phone:713-500-5650
Practice Address - Fax:713-500-0588
Is Sole Proprietor?:No
Enumeration Date:2016-05-02
Last Update Date:2019-02-28
Deactivation Date:2016-12-30
Deactivation Code:
Reactivation Date:2017-05-18
Provider Licenses
StateLicense IDTaxonomies
TX390200000X
FL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program