MEDICARE: JORGE LUIS OPORTA TELLEZ SA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246ZC0007X	Surgical Assistant	24-336	FL

General Provider Information

NPI Number	:	1023853785
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORGE LUIS OPORTA TELLEZ SA-C

Provider Business Mailing Address
First Line	:	5990 TERRACE PARK DR N UNIT 209
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33709-1153
Country	:	US
Telephone Number	:	727-598-3703
Fax Number	:

Provider Business Practice Location Address
First Line	:	5990 TERRACE PARK DR N UNIT 209
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33709-1153
Country	:	US
Telephone Number	:	727-598-3703
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/26/2024
Last Update Date	:	06/26/2024

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