Provider Demographics
NPI:1134873441
Name:FONT, JORGE
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:FONT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6007 N 18TH ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-3512
Mailing Address - Country:US
Mailing Address - Phone:813-391-4639
Mailing Address - Fax:813-519-1936
Practice Address - Street 1:6007 N 18TH ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-3512
Practice Address - Country:US
Practice Address - Phone:813-391-4639
Practice Address - Fax:813-519-1936
Is Sole Proprietor?:No
Enumeration Date:2022-02-06
Last Update Date:2022-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL691647396Medicaid