Healthcare Provider Details

I. General information

NPI: 1831783471
Provider Name (Legal Business Name): JORGE MEJIA CO LO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2021
Last Update Date: 02/24/2021
Certification Date: 02/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3870 NW 83RD ST
GAINESVILLE FL
32606-5601
US

IV. Provider business mailing address

3870 NW 83RD ST
GAINESVILLE FL
32606-5601
US

V. Phone/Fax

Practice location:
  • Phone: 352-331-4221
  • Fax: 352-332-8074
Mailing address:
  • Phone: 352-331-4221
  • Fax: 352-332-8074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberORT351
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: