Healthcare Provider Details

I. General information

NPI: 1063642692
Provider Name (Legal Business Name): JOSE MARTIN JORGE RRT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MARTIN JORGE RRT

II. Dates (important events)

Enumeration Date: 07/16/2009
Last Update Date: 07/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 POINTER LN
GORDONSVILLE VA
22942-6864
US

IV. Provider business mailing address

137 POINTER LN
GORDONSVILLE VA
22942-6864
US

V. Phone/Fax

Practice location:
  • Phone: 434-984-2547
  • Fax:
Mailing address:
  • Phone: 434-984-2547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2279G1100X
TaxonomyGeneral Care Registered Respiratory Therapist
License Number0117003597
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: