Provider Demographics
NPI:1639103609
Name:ATIENZA, JASON TIA (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:TIA
Last Name:ATIENZA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:WILFRED JASON
Other - Middle Name:TIA
Other - Last Name:ATIENZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:32 W GORE ST
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1134
Mailing Address - Country:US
Mailing Address - Phone:407-649-6151
Mailing Address - Fax:321-943-6658
Practice Address - Street 1:32 W GORE ST
Practice Address - Street 2:5TH FLOOR
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1134
Practice Address - Country:US
Practice Address - Phone:407-649-6151
Practice Address - Fax:321-943-6658
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA86516208100000X
FLME 116489208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009173800Medicaid
FLME116489OtherMEDICAL LICENSE
FLME116489OtherMEDICAL LICENSE