Provider Demographics
NPI:1750407086
Name:JACQUEMIN, THIERRY O (DO)
Entity type:Individual
Prefix:DR
First Name:THIERRY
Middle Name:O
Last Name:JACQUEMIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10254 SW 128TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-2321
Mailing Address - Country:US
Mailing Address - Phone:305-733-9204
Mailing Address - Fax:
Practice Address - Street 1:10254 SW 128TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-2321
Practice Address - Country:US
Practice Address - Phone:305-733-9204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 9856207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBS885XMedicare UPIN
FLBR885CMedicare PIN