Provider Demographics
NPI:1023853785
Name:OPORTA TELLEZ, JORGE LUIS (SA-C)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:LUIS
Last Name:OPORTA TELLEZ
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 1:5990 TERRACE PARK DR N UNIT 209
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33709-1153
Mailing Address - Country:US
Mailing Address - Phone:727-598-3703
Mailing Address - Fax:
Practice Address - Street 1:5990 TERRACE PARK DR N UNIT 209
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-1153
Practice Address - Country:US
Practice Address - Phone:727-598-3703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24-336246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant