Provider Demographics
NPI:1558822205
Name:CALDERON, JOSE LUIS (APRN 11001721)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:LUIS
Last Name:CALDERON
Suffix:
Gender:M
Credentials:APRN 11001721
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11531 SW 6TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33174-3701
Mailing Address - Country:US
Mailing Address - Phone:786-715-8969
Mailing Address - Fax:
Practice Address - Street 1:11531 SW 6TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33174-3701
Practice Address - Country:US
Practice Address - Phone:786-715-8969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-26
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11001721207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine