Provider Demographics
NPI:1629042403
Name:JO, ROBERTO (MD)
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:
Last Name:JO
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 1:1200 RIVERPLACE BLVD
Mailing Address - Street 2:SUITE 620
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-9046
Mailing Address - Country:US
Mailing Address - Phone:904-396-6620
Mailing Address - Fax:904-396-6528
Practice Address - Street 1:1200 RIVERPLACE BLVD
Practice Address - Street 2:SUITE 620
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-9046
Practice Address - Country:US
Practice Address - Phone:904-396-6620
Practice Address - Fax:904-396-6528
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME93289207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL274600000Medicaid
FL274600000Medicaid
FL28752ZMedicare PIN
FLI42289Medicare UPIN