Provider Demographics
NPI:1518955608
Name:BASAGOITIA, JOSE SIMON (MD)
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:SIMON
Last Name:BASAGOITIA
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 1:3661 S MIAMI AVE
Mailing Address - Street 2:SUITE 705
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33133-4236
Mailing Address - Country:US
Mailing Address - Phone:305-854-0445
Mailing Address - Fax:305-854-5099
Practice Address - Street 1:3661 S MIAMI AVE
Practice Address - Street 2:SUITE 705
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33133-4236
Practice Address - Country:US
Practice Address - Phone:305-854-0445
Practice Address - Fax:305-854-5099
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0038838207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL057125300Medicaid
FL057125300Medicaid
FL95817Medicare ID - Type Unspecified