Provider Demographics
NPI:1700837317
Name:DE JESUS, DANTE V (MD)
Entity Type:Individual
Prefix:
First Name:DANTE
Middle Name:V
Last Name:DE JESUS
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 1:440 TAYLOR RD
Mailing Address - Street 2:SUITE 3380
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-3588
Mailing Address - Country:US
Mailing Address - Phone:334-213-6281
Mailing Address - Fax:334-213-6288
Practice Address - Street 1:440 TAYLOR RD
Practice Address - Street 2:SUITE 3380
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-3588
Practice Address - Country:US
Practice Address - Phone:334-213-6281
Practice Address - Fax:334-213-6288
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL26777207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051556282Medicaid
AL1326182486OtherHOSPITAL PHYSICIAN SERVICES OF CENTRAL ALABAMA
AL1326182486OtherHOSPITAL PHYSICIAN SERVICES OF CENTRAL ALABAMA
ALI33967Medicare UPIN
AL051556282Medicare ID - Type Unspecified