Provider Demographics
NPI:1336261346
Name:MESA, JOSE MIGUEL
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:MIGUEL
Last Name:MESA
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 1:5370 PALM AVE LOCAL #2
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012
Mailing Address - Country:US
Mailing Address - Phone:305-820-9771
Mailing Address - Fax:305-820-9771
Practice Address - Street 1:5370 PALM AVE LOCAL #2
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012
Practice Address - Country:US
Practice Address - Phone:305-820-9771
Practice Address - Fax:305-820-9771
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO5794156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician