Healthcare Provider Details

I. General information

NPI: 1649727074
Provider Name (Legal Business Name): JOSE G CEVALLOS MD-PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 12/08/2023
Certification Date: 12/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15643 CYPRESS PARK DR
WELLINGTON FL
33414-6341
US

IV. Provider business mailing address

15643 CYPRESS PARK DR
WELLINGTON FL
33414-6341
US

V. Phone/Fax

Practice location:
  • Phone: 305-790-6544
  • Fax:
Mailing address:
  • Phone: 305-790-6544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License NumberME114288
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JOSE GUSTAVO CEVALLOS
Title or Position: PRESIDENT
Credential: MD
Phone: 305-790-6544