Healthcare Provider Details

I. General information

NPI: 1477967545
Provider Name (Legal Business Name): JORGE L CORDOVA - RUIZ M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2014
Last Update Date: 03/04/2022
Certification Date: 03/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 DEERFIELD PRESERVE BLVD
ST AUGUSTINE FL
32086-5966
US

IV. Provider business mailing address

100 DEERFIELD PRESERVE BLVD
ST AUGUSTINE FL
32086-5966
US

V. Phone/Fax

Practice location:
  • Phone: 904-829-0814
  • Fax:
Mailing address:
  • Phone: 904-829-0814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number019114
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: