Provider Demographics
NPI:1518918804
Name:CANNIZZARO DE JESUS, JOSEPH (MD)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:
Last Name:CANNIZZARO DE JESUS
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:PMB 134
Mailing Address - Street 2:PO BOX 2000
Mailing Address - City:MERCEDITA
Mailing Address - State:PR
Mailing Address - Zip Code:00715-8000
Mailing Address - Country:US
Mailing Address - Phone:787-844-7336
Mailing Address - Fax:787-651-7756
Practice Address - Street 1:1255 PASEO LAS MONJITAS
Practice Address - Street 2:PLAZA LAS MONJITAS SUITE 204
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00730-4222
Practice Address - Country:US
Practice Address - Phone:787-844-7336
Practice Address - Fax:787-651-7756
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11238208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
G66294Medicare UPIN
89298Medicare ID - Type Unspecified