Healthcare Provider Details

I. General information

NPI: 1447458229
Provider Name (Legal Business Name): JORGE GILETE SOSA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 12/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 N TEMPLE AVE
STARKE FL
32091-1960
US

IV. Provider business mailing address

1801 N TEMPLE AVE
STARKE FL
32091-1960
US

V. Phone/Fax

Practice location:
  • Phone: 904-964-7732
  • Fax: 904-964-3024
Mailing address:
  • Phone: 904-964-7732
  • Fax: 904-964-3024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number014356
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberACN204
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: