Healthcare Provider Details

I. General information

NPI: 1720633548
Provider Name (Legal Business Name): JORGE DE LA PAZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2019
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23429 SW 129TH AVE
PRINCETON FL
33032-9219
US

IV. Provider business mailing address

23429 SW 129TH AVE
PRINCETON FL
33032-9219
US

V. Phone/Fax

Practice location:
  • Phone: 786-314-3691
  • Fax:
Mailing address:
  • Phone: 786-314-3691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-25-85699
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: