Provider Demographics
NPI:1255612065
Name:AMISIAL, JEAN MICHEL (MD)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:MICHEL
Last Name:AMISIAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1190 NW 95TH ST STE 405
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33150-2067
Mailing Address - Country:US
Mailing Address - Phone:305-835-9264
Mailing Address - Fax:305-835-9354
Practice Address - Street 1:1190 NW 95TH ST
Practice Address - Street 2:405
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33150-2063
Practice Address - Country:US
Practice Address - Phone:305-835-9264
Practice Address - Fax:305-835-9354
Is Sole Proprietor?:No
Enumeration Date:2011-09-07
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME110803207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0045030000Medicaid
FL0045030000Medicaid