Provider Demographics
NPI:1558308783
Name:BACA, JOSE FRANCISCO (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:FRANCISCO
Last Name:BACA
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 1:777 E 25TH ST
Mailing Address - Street 2:SUITE 509
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33013
Mailing Address - Country:US
Mailing Address - Phone:305-696-7557
Mailing Address - Fax:305-696-7469
Practice Address - Street 1:777 E 25TH ST
Practice Address - Street 2:SUITE 509
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33013
Practice Address - Country:US
Practice Address - Phone:305-696-7557
Practice Address - Fax:305-696-7469
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME57517207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL371253200Medicaid
FL371253200Medicaid
FL18128Medicare ID - Type Unspecified