Provider Demographics
NPI: | 1710113337 |
---|---|
Name: | CHING, JESSICA ALLEN (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | JESSICA |
Middle Name: | ALLEN |
Last Name: | CHING |
Suffix: | |
Gender: | F |
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: | PO BOX 100108 |
Mailing Address - Street 2: | J402 |
Mailing Address - City: | GAINESVILLE |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 32610-0138 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 352-273-8670 |
Mailing Address - Fax: | 352-273-8639 |
Practice Address - Street 1: | 1600 SW ARCHER RD |
Practice Address - Street 2: | |
Practice Address - City: | GAINESVILLE |
Practice Address - State: | FL |
Practice Address - Zip Code: | 32610-0138 |
Practice Address - Country: | US |
Practice Address - Phone: | 352-273-8670 |
Practice Address - Fax: | 352-273-8639 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2009-06-10 |
Last Update Date: | 2016-11-04 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
390200000X | ||
FL | ME111226 | 2086S0122X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2086S0122X | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
No | 390200000X | Student, Health Care | Student in an Organized Health Care Education/Training Program |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | 018721100 | Medicaid | |
FL | IS181Z | Medicare PIN |