Healthcare Provider Details

I. General information

NPI: 1720482854
Provider Name (Legal Business Name): MR. JONATHAN GESKUS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2014
Last Update Date: 08/05/2021
Certification Date: 08/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14750 NW 44TH CT
OPA LOCKA FL
33054-2304
US

IV. Provider business mailing address

14750 NW 44TH CT
OPA LOCKA FL
33054-2304
US

V. Phone/Fax

Practice location:
  • Phone: 305-953-2266
  • Fax: 305-953-2251
Mailing address:
  • Phone: 305-953-2266
  • Fax: 305-953-2251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: