Healthcare Provider Details

I. General information

NPI: 1639103609
Provider Name (Legal Business Name): JASON TIA ATIENZA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: WILFRED JASON TIA ATIENZA

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 04/04/2025
Certification Date: 04/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 W GORE ST 5TH FLOOR
ORLANDO FL
32806-1134
US

IV. Provider business mailing address

32 W GORE ST 5TH FLOOR
ORLANDO FL
32806-1134
US

V. Phone/Fax

Practice location:
  • Phone: 209-566-3292
  • Fax: 321-943-6658
Mailing address:
  • Phone: 209-566-3292
  • Fax: 321-943-6658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberA86516
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberME 116489
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: