Healthcare Provider Details

I. General information

NPI: 1811717572
Provider Name (Legal Business Name): JORGE E PEREZ LEYVA CCMA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2024
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10711 SW 216TH ST UNIT 203
MIAMI FL
33170-3139
US

IV. Provider business mailing address

10711 SW 216TH ST UNIT 203
MIAMI FL
33170-3139
US

V. Phone/Fax

Practice location:
  • Phone: 786-764-3230
  • Fax:
Mailing address:
  • Phone: 786-764-3230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberF8T4Z7Y8
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-385573
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: