MEDICARE: DR. JUAQUITO MARIO JORGE MD

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	208600000X	Surgery Physician	036129844	IL
2	208600000X	Surgery Physician	102252	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629206511
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JUAQUITO MARIO JORGE MD

Provider Business Mailing Address
First Line	:	818 SAINT SEBASTIAN WAY STE 200
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30901-2652
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	818 SAINT SEBASTIAN WAY STE 200
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30901-2652
Country	:	US
Telephone Number	:	706-774-8940
Fax Number	:

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

Provider Enumeration Date	:	06/30/2009
Last Update Date	:	01/15/2025

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