Provider Demographics
NPI:1568485969
Name:JUNCOSA, EMILIO JORGE (MD)
Entity Type:Individual
Prefix:
First Name:EMILIO
Middle Name:JORGE
Last Name:JUNCOSA
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 1:900 BISCAYNE BLVD
Mailing Address - Street 2:5006
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33132-1561
Mailing Address - Country:US
Mailing Address - Phone:954-441-9595
Mailing Address - Fax:
Practice Address - Street 1:12311 TAFT ST
Practice Address - Street 2:SUITE #1
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-4384
Practice Address - Country:US
Practice Address - Phone:954-441-9595
Practice Address - Fax:954-441-9636
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME56624174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE75864Medicare ID - Type UnspecifiedSTATE MEDICARE NUMBER