Healthcare Provider Details

I. General information

NPI: 1578945598
Provider Name (Legal Business Name): EDDY J DE JESUS M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 09/02/2020
Certification Date: 09/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

722 RIVERSIDE DR
CORAL SPRINGS FL
33071-7008
US

IV. Provider business mailing address

1650 GRAND CONCOURSE
BRONX NY
10457-7606
US

V. Phone/Fax

Practice location:
  • Phone: 954-345-4333
  • Fax: 954-345-4334
Mailing address:
  • Phone: 718-960-1234
  • Fax: 718-960-2055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberME143523
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: