Healthcare Provider Details

I. General information

NPI: 1053623371
Provider Name (Legal Business Name): JAIME L MOREL RUIZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2010
Last Update Date: 04/14/2020
Certification Date: 04/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

743 SPRING ST NE
GAINESVILLE GA
30501-3715
US

IV. Provider business mailing address

PO BOX 3293
INDIANAPOLIS IN
46206-3293
US

V. Phone/Fax

Practice location:
  • Phone: 770-219-7828
  • Fax:
Mailing address:
  • Phone: 317-614-9863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberME128532
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number72053
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: