Provider Demographics
NPI:1922083948
Name:PICHARDO, JESUS RAFAEL (MD)
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:RAFAEL
Last Name:PICHARDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JESUS
Other - Middle Name:R
Other - Last Name:PICHARDO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:6900 TAVISTOCK LAKES BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32827-7592
Mailing Address - Country:US
Mailing Address - Phone:321-758-2966
Mailing Address - Fax:407-286-4515
Practice Address - Street 1:1130 S SEMORAN BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807-1457
Practice Address - Country:US
Practice Address - Phone:407-382-1376
Practice Address - Fax:321-235-3232
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN320208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
0083154Medicare ID - Type Unspecified
F69528Medicare UPIN