Provider Demographics
NPI:1649727074
Name:JOSE G CEVALLOS MD-PA
Entity type:Organization
Organization Name:JOSE G CEVALLOS MD-PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:GUSTAVO
Authorized Official - Last Name:CEVALLOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-790-6544
Mailing Address - Street 1:15643 CYPRESS PARK DR
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-6341
Mailing Address - Country:US
Mailing Address - Phone:305-790-6544
Mailing Address - Fax:
Practice Address - Street 1:15643 CYPRESS PARK DR
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-6341
Practice Address - Country:US
Practice Address - Phone:305-790-6544
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QH0100X, 261QP2300X
FLME114288252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL011046600Medicaid
FLHN973ZMedicare Oscar/Certification