Provider Demographics
NPI:1811352669
Name:CHIRIBOGA, JAVIER
Entity type:Individual
Prefix:
First Name:JAVIER
Middle Name:
Last Name:CHIRIBOGA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15300 S JOG RD STE 101
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33446-2164
Mailing Address - Country:US
Mailing Address - Phone:561-819-3100
Mailing Address - Fax:561-819-3119
Practice Address - Street 1:8545 JARED WAY
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-7644
Practice Address - Country:US
Practice Address - Phone:561-866-3953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-22
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11007504363L00000X
WI15-699246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant