=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013034172
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JILOCA DEJESUS JILOCA MDPA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 A FRONT STREET
-----------------------------------------------------
City | SEAFORD
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19973
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-629-4569
-----------------------------------------------------
Fax | 302-628-4669
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 105 A FRONT STREET
-----------------------------------------------------
City | SEAFORD
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19973
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-629-4569
-----------------------------------------------------
Fax | 302-628-4669
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT VICE PRESIDENT
-----------------------------------------------------
Name | EDUARDO L JILOCA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 302-629-4569
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------