Healthcare Provider Details

I. General information

NPI: 1447287941
Provider Name (Legal Business Name): JORGE A BEZERRA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 12/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 BURNET AVE ML 2010
CINCINNATI OH
45229-3039
US

IV. Provider business mailing address

3333 BURNET AVE ML 2010
CINCINNATI OH
45229-3026
US

V. Phone/Fax

Practice location:
  • Phone: 513-636-4415
  • Fax: 513-636-7805
Mailing address:
  • Phone: 513-636-4415
  • Fax: 513-636-7805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number35.060978
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberTP228
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: