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General NPI Number Information
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NPI Number | 1972166924
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Entity Type | Individual
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Provider Name | JOSE R MIJARES SA-C
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Gender | Male
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Dates
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Enumeration Date | 04/16/2019
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Last Update Date | 04/19/2019
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Provider Practice Location Address
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Address Line | 255 CITRUS TOWER BLVD STE 101
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City | CLERMONT
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State | FL
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Zip | 34711-1906
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Country | US
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Telephone | 352-394-0893
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Fax | 352-243-1188
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Provider Business Mailing Address
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Address Line | 2844 MAGNOLIA BLOSSOM CIR
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City | CLERMONT
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State | FL
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Zip | 34711-7493
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Country | US
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Telephone | 352-460-2569
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 246ZC0007X
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Taxonomy Name | Surgical Assistant
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License Number | 19-192
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License Number State |
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