Provider Demographics
NPI:1730464751
Name:NUNES, JACK MARTINS (PT)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:MARTINS
Last Name:NUNES
Suffix:
Gender:M
Credentials:PT
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 166482
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33116-6482
Mailing Address - Country:US
Mailing Address - Phone:305-275-5677
Mailing Address - Fax:305-279-7989
Practice Address - Street 1:9117 SW 87TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-2302
Practice Address - Country:US
Practice Address - Phone:305-279-2335
Practice Address - Fax:305-279-7989
Is Sole Proprietor?:No
Enumeration Date:2011-10-21
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT26672174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT 26672OtherMEDICAL LICENSE