Provider Demographics
NPI:1669428108
Name:LLERA, JORGE L (MD)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:L
Last Name:LLERA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 S J ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4933
Mailing Address - Country:US
Mailing Address - Phone:253-426-6963
Mailing Address - Fax:253-838-6418
Practice Address - Street 1:1717 S J ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4933
Practice Address - Country:US
Practice Address - Phone:253-426-6963
Practice Address - Fax:253-838-6418
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00021285207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0171297OtherLIWA
WALL3003OtherBSWA
WA8609406Medicaid
WAG8881675Medicare PIN
WAG8881674Medicare PIN
WA0171297OtherLIWA
WAP00222748Medicare PIN
WALL3003OtherBSWA