Provider Demographics
NPI:1669130860
Name:LEDEZMA SALAZAR, JORGE ALEXANDER (SA-C)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:ALEXANDER
Last Name:LEDEZMA SALAZAR
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18260 NW 59TH AVE APT 203
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-5691
Mailing Address - Country:US
Mailing Address - Phone:786-230-4381
Mailing Address - Fax:
Practice Address - Street 1:18260 NW 59TH AVE APT 203
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-5691
Practice Address - Country:US
Practice Address - Phone:786-230-4381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-04
Last Update Date:2021-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21-546246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant