Provider Demographics
NPI:1578978516
Name:CONDE, JENNIFER MOSCOSO (DO)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MOSCOSO
Last Name:CONDE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:MARIE
Other - Last Name:MOSCOSO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:5627 SKYTOP DR
Mailing Address - Street 2:
Mailing Address - City:LITHIA
Mailing Address - State:FL
Mailing Address - Zip Code:33547-4165
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5627 SKYOP DRIVE
Practice Address - Street 2:
Practice Address - City:LITHIA
Practice Address - State:FL
Practice Address - Zip Code:33547
Practice Address - Country:US
Practice Address - Phone:813-530-6511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-29
Last Update Date:2024-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS12902207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIZ758ZOtherMEDICARE
FLIZ758ZOtherMEDICARE