Provider Demographics
NPI:1922236736
Name:CEVALLOS, JOSE GUSTAVO (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:GUSTAVO
Last Name:CEVALLOS
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 1:5353 N FEDERAL HWY STE 400406
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-3245
Mailing Address - Country:US
Mailing Address - Phone:954-938-2843
Mailing Address - Fax:
Practice Address - Street 1:5353 N FEDERAL HWY STE 400
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-3244
Practice Address - Country:US
Practice Address - Phone:954-938-2843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXU5083207R00000X
FLME114288207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU5083OtherTEXAS MEDICAL LICENSE
FL011046600Medicaid
FLME114288OtherFLORIDA MEDICAL LICENSE