Provider Demographics
NPI:1659543981
Name:BOSQUE-PEREZ, MONIQUE (DO)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:BOSQUE-PEREZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 44008
Mailing Address - Street 2:UFJP PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:781 EDGEWOOD AVE N
Practice Address - Street 2:UFJP COMMONWEALTH FAMILY PRACTICE
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32254
Practice Address - Country:US
Practice Address - Phone:904-633-0500
Practice Address - Fax:904-384-4663
Is Sole Proprietor?:No
Enumeration Date:2008-03-26
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLUS1501207Q00000X
FLOS10679207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0015087-00Medicaid
FL145UKOtherBCBS - FL
FLCH586ZMedicare PIN
FLP00768035Medicare PIN