Healthcare Provider Details

I. General information

NPI: 1114601192
Provider Name (Legal Business Name): JORGE LUIS CARRILLO MOYA HSE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1321 NW 14TH ST BLDG SUITE505
MIAMI FL
33125-1673
US

IV. Provider business mailing address

1321 NW 14TH ST BLDG SUITE505
MIAMI FL
33125-1673
US

V. Phone/Fax

Practice location:
  • Phone: 305-243-6704
  • Fax: 305-243-6191
Mailing address:
  • Phone: 305-243-6704
  • Fax: 305-243-6191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberHSE36492
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: