Provider Demographics
NPI:1639493158
Name:JAGS MEDICAL OFFICE INC
Entity Type:Organization
Organization Name:JAGS MEDICAL OFFICE INC
Other - Org Name:JAGS MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR/GENERAL MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VIOLETA
Authorized Official - Middle Name:L
Authorized Official - Last Name:CHACON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-220-2338
Mailing Address - Street 1:8420 SW 21ST ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-1029
Mailing Address - Country:US
Mailing Address - Phone:305-220-2338
Mailing Address - Fax:305-223-1210
Practice Address - Street 1:8748 SW 8TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33174-3201
Practice Address - Country:US
Practice Address - Phone:305-220-2338
Practice Address - Fax:305-223-1210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-26
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010777400Medicaid
FLHS036AMedicare PIN