Healthcare Provider Details

I. General information

NPI: 1497757645
Provider Name (Legal Business Name): SAMUEL DEJESUS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 08/25/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 W GORE ST STE 204
ORLANDO FL
32806-1134
US

IV. Provider business mailing address

32 W GORE ST STE 204
ORLANDO FL
32806-1134
US

V. Phone/Fax

Practice location:
  • Phone: 407-649-6884
  • Fax: 407-245-7059
Mailing address:
  • Phone: 407-649-6884
  • Fax: 407-245-7059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberME78134
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: