Provider Demographics
NPI:1508925496
Name:DE LA PEDRAJA, JORGE LUIS (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:LUIS
Last Name:DE LA PEDRAJA
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 1:167 MAJORCA AVE
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-4553
Mailing Address - Country:US
Mailing Address - Phone:305-441-9144
Mailing Address - Fax:305-448-8994
Practice Address - Street 1:167 MAJORCA AVE
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-4553
Practice Address - Country:US
Practice Address - Phone:305-441-9144
Practice Address - Fax:305-448-8994
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME77828208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH39921Medicare UPIN
FLE5681Medicare ID - Type Unspecified