Provider Demographics
NPI:1396924841
Name:DR JORGE TRAVIESO M D P A
Entity type:Organization
Organization Name:DR JORGE TRAVIESO M D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAVIESO
Authorized Official - Suffix:I
Authorized Official - Credentials:M D P A
Authorized Official - Phone:305-825-0587
Mailing Address - Street 1:2369 WEST 52 ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016
Mailing Address - Country:US
Mailing Address - Phone:305-825-0587
Mailing Address - Fax:
Practice Address - Street 1:2369 WEST 52 ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016
Practice Address - Country:US
Practice Address - Phone:305-825-0587
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-01
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL25390Medicare PIN
FLF83684Medicare UPIN