MEDICARE: MR. JORGE L CORDOVA - RUIZ M.D

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	208D00000X	General Practice Physician	019114	PR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1477967545	OTHER	PR	1477967545

General Provider Information

NPI Number	:	1477967545
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JORGE L CORDOVA - RUIZ M.D

Provider Business Mailing Address
First Line	:	100 DEERFIELD PRESERVE BLVD
Second Line	:
City	:	ST AUGUSTINE
State	:	FL
Zip	:	32086-5966
Country	:	US
Telephone Number	:	904-829-0814
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 DEERFIELD PRESERVE BLVD
Second Line	:
City	:	ST AUGUSTINE
State	:	FL
Zip	:	32086-5966
Country	:	US
Telephone Number	:	904-829-0814
Fax Number	:

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

Provider Enumeration Date	:	06/17/2014
Last Update Date	:	03/04/2022

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