Provider Demographics
NPI:1760466346
Name:PLASENCIA, JORGE (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:PLASENCIA
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 1:4449 FASHION SQUARE BLVD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-5217
Mailing Address - Country:US
Mailing Address - Phone:989-790-0007
Mailing Address - Fax:989-790-7547
Practice Address - Street 1:4705 TOWNE CTR
Practice Address - Street 2:SUITE 202
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-2818
Practice Address - Country:US
Practice Address - Phone:989-791-3401
Practice Address - Fax:989-791-3466
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-06
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301068139207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4767454Medicaid
MI0P20440Medicare ID - Type Unspecified
MI4767454Medicaid