Provider Demographics
NPI:1518580562
Name:DE LA ROSA PEREZ, JORGE NELSON (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:NELSON
Last Name:DE LA ROSA PEREZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:9472 NW 120TH ST
Mailing Address - Street 2:APT 721
Mailing Address - City:HIALEAH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33018-4196
Mailing Address - Country:US
Mailing Address - Phone:786-413-7383
Mailing Address - Fax:786-322-2317
Practice Address - Street 1:2750 W 68TH ST # 127-128
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-5446
Practice Address - Country:US
Practice Address - Phone:305-558-0765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-26
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN1357208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice