Healthcare Provider Details

I. General information

NPI: 1225631203
Provider Name (Legal Business Name): JESUS RAMIRO DAVILA-ROSA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2020
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 RIVERVIEW ST
JACKSONVILLE FL
32208-2657
US

IV. Provider business mailing address

2040 RIVERVIEW ST
JACKSONVILLE FL
32208-2657
US

V. Phone/Fax

Practice location:
  • Phone: 904-224-5437
  • Fax:
Mailing address:
  • Phone: 904-224-5437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number863-PA
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPACN13
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: