Provider Demographics
NPI:1972166924
Name:MIJARES, JOSE R (SA-C)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:R
Last Name:MIJARES
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2844 MAGNOLIA BLOSSOM CIR
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-7493
Mailing Address - Country:US
Mailing Address - Phone:352-460-2569
Mailing Address - Fax:
Practice Address - Street 1:255 CITRUS TOWER BLVD STE 101
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-1906
Practice Address - Country:US
Practice Address - Phone:352-394-0893
Practice Address - Fax:352-243-1188
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-16
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
19-192246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant