Provider Demographics
NPI:1760424519
Name:SIFUENTES, JORGE L (MD)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:L
Last Name:SIFUENTES
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 1:951 COMMERCE PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-4040
Mailing Address - Country:US
Mailing Address - Phone:419-998-4575
Mailing Address - Fax:419-998-4586
Practice Address - Street 1:1001 BELLEFONTAINE AVE
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-2800
Practice Address - Country:US
Practice Address - Phone:419-228-3335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35055919207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000175871OtherANTHEM
OH050077131OtherRAILROAD MEDICARE
OH0788876Medicaid
OH000000175871OtherANTHEM
OH0788876Medicaid