Provider Demographics
NPI:1497757645
Name:DEJESUS, SAMUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
Last Name:DEJESUS
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 1:32 W GORE ST STE 204
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1134
Mailing Address - Country:US
Mailing Address - Phone:407-649-6884
Mailing Address - Fax:407-245-7059
Practice Address - Street 1:32 W GORE ST STE 204
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1134
Practice Address - Country:US
Practice Address - Phone:407-649-6884
Practice Address - Fax:407-245-7059
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78134208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL259597400Medicaid
FLH14964Medicare UPIN
FLE4079ZMedicare ID - Type Unspecified
FL259597400Medicaid
FLE4079WMedicare PIN