Healthcare Provider Details

I. General information

NPI: 1508024167
Provider Name (Legal Business Name): SEGUNDO JAIME GONZALEZ ESCOLA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2008
Last Update Date: 06/19/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 NW 82ND AVE STE 305
PLANTATION FL
33324-1855
US

IV. Provider business mailing address

304 INDIAN TRCE
WESTON FL
33326-2996
US

V. Phone/Fax

Practice location:
  • Phone: 754-200-1617
  • Fax: 954-726-0874
Mailing address:
  • Phone: 754-200-1617
  • Fax: 954-656-0108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME113213
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2086H0002X
TaxonomyHospice and Palliative Medicine (Surgery) Physician
License NumberME 113213
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number23058
License Number StatePR
# 4
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberME113213
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: