Provider Demographics
NPI:1497286389
Name:PALMA, JORGE
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:PALMA
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 1:11645 BISCAYNE BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33181-3138
Mailing Address - Country:US
Mailing Address - Phone:305-538-8835
Mailing Address - Fax:786-574-5565
Practice Address - Street 1:11645 BISCAYNE BLVD STE 102
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33181-3138
Practice Address - Country:US
Practice Address - Phone:305-538-8835
Practice Address - Fax:786-574-5565
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-23
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL002545100171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002545100Medicaid