Provider Demographics
NPI:1275774598
Name:HUERTA, VIRGILIO R (MD)
Entity Type:Individual
Prefix:DR
First Name:VIRGILIO
Middle Name:R
Last Name:HUERTA
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:PO BOX 44004
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4004
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-348-5627
Practice Address - Street 1:820 PRUDENTIAL DR STE 304
Practice Address - Street 2:CREDENTIALING DEPARTMENT
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8205
Practice Address - Country:US
Practice Address - Phone:904-346-3649
Practice Address - Fax:904-348-5627
Is Sole Proprietor?:No
Enumeration Date:2009-03-17
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2024-0229207R00000X
FLME119776207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013561200Medicaid
FLP01387566OtherRAILROAD MEDICARE
FLHY617ZMedicare PIN