Healthcare Provider Details

I. General information

NPI: 1689645921
Provider Name (Legal Business Name): JOSE ANTONIO URDANETA-JAIMES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 11/02/2021
Certification Date: 11/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 N CENTRAL AVE SUITE B
KISSIMMEE FL
34741-4405
US

IV. Provider business mailing address

1121 N CENTRAL AVE SUITE B
KISSIMMEE FL
34741-4405
US

V. Phone/Fax

Practice location:
  • Phone: 407-933-1221
  • Fax: 407-933-0747
Mailing address:
  • Phone: 407-933-1221
  • Fax: 407-933-0747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberME84353
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberME84353
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: