Healthcare Provider Details

I. General information

NPI: 1972166924
Provider Name (Legal Business Name): JOSE R MIJARES SA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2019
Last Update Date: 04/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 CITRUS TOWER BLVD STE 101
CLERMONT FL
34711-1906
US

IV. Provider business mailing address

2844 MAGNOLIA BLOSSOM CIR
CLERMONT FL
34711-7493
US

V. Phone/Fax

Practice location:
  • Phone: 352-394-0893
  • Fax: 352-243-1188
Mailing address:
  • Phone: 352-460-2569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number19-192
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: