Healthcare Provider Details

I. General information

NPI: 1023307832
Provider Name (Legal Business Name): SERGIO SAN JOSE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2011
Last Update Date: 10/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 W 76TH ST APT 206
HIALEAH FL
33016-5649
US

IV. Provider business mailing address

2620 W 76TH ST APT 206
HIALEAH FL
33016-5649
US

V. Phone/Fax

Practice location:
  • Phone: 786-897-0578
  • Fax:
Mailing address:
  • Phone: 786-897-0578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberOS12497
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: