Provider Demographics
NPI:1396133450
Name:JOSE A DE JESUS MD PA
Entity type:Organization
Organization Name:JOSE A DE JESUS MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:A
Authorized Official - Last Name:DE JESUS-CARBUCCIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-236-7741
Mailing Address - Street 1:PO BOX 9668
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32513-9668
Mailing Address - Country:US
Mailing Address - Phone:850-478-1312
Mailing Address - Fax:850-474-9060
Practice Address - Street 1:1620 S CONGRESS AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PALM SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33461-2128
Practice Address - Country:US
Practice Address - Phone:850-561-2032
Practice Address - Fax:561-968-1046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-24
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008LMOtherFLORIDA BLUE