Provider Demographics
NPI:1689682296
Name:PUERTO, JUAN RIGOBERTO (MD)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:RIGOBERTO
Last Name:PUERTO
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 1:555 N 15TH ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:IMMOKALEE
Mailing Address - State:FL
Mailing Address - Zip Code:34142-2824
Mailing Address - Country:US
Mailing Address - Phone:239-657-2779
Mailing Address - Fax:239-657-3335
Practice Address - Street 1:555 N 15TH ST UNIT A
Practice Address - Street 2:
Practice Address - City:IMMOKALEE
Practice Address - State:FL
Practice Address - Zip Code:34142-2824
Practice Address - Country:US
Practice Address - Phone:239-657-2779
Practice Address - Fax:239-657-3335
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME42490208D00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL068069900Medicaid
FLD52120Medicare UPIN
FL068069900Medicaid