Healthcare Provider Details

I. General information

NPI: 1689682296
Provider Name (Legal Business Name): JUAN RIGOBERTO PUERTO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 04/25/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 N 15TH ST UNIT A
IMMOKALEE FL
34142-2824
US

IV. Provider business mailing address

555 N 15TH ST UNIT A
IMMOKALEE FL
34142-2824
US

V. Phone/Fax

Practice location:
  • Phone: 239-657-2779
  • Fax: 239-657-3335
Mailing address:
  • Phone: 239-657-2779
  • Fax: 239-657-3335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME42490
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: