Provider Demographics
NPI:1770910911
Name:MARISELA C JAQUEZ-GUTIERREZ LLC
Entity type:Organization
Organization Name:MARISELA C JAQUEZ-GUTIERREZ LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARISELA
Authorized Official - Middle Name:C
Authorized Official - Last Name:JAQUEZ-GUTIERREZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-392-6784
Mailing Address - Street 1:8181 NW 36TH ST
Mailing Address - Street 2:SUITE 1906
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166-6671
Mailing Address - Country:US
Mailing Address - Phone:305-392-6784
Mailing Address - Fax:305-392-6784
Practice Address - Street 1:8181 NW 36TH ST
Practice Address - Street 2:SUITE 1906
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166-6671
Practice Address - Country:US
Practice Address - Phone:305-392-6784
Practice Address - Fax:305-392-6784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 70979261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006685400Medicaid
FLG45928Medicare UPIN