Healthcare Provider Details

I. General information

NPI: 1194771386
Provider Name (Legal Business Name): JUAN M ESCOBAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 01/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7664 S US HIGHWAY 1
PORT ST LUCIE FL
34952-2320
US

IV. Provider business mailing address

7664 S US HIGHWAY 1
PORT ST LUCIE FL
34952-2320
US

V. Phone/Fax

Practice location:
  • Phone: 772-879-0699
  • Fax: 772-879-6650
Mailing address:
  • Phone: 772-879-0699
  • Fax: 772-879-6650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number81753
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: