Provider Demographics
NPI:1063436046
Name:JAEN, JOSE E (MD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:E
Last Name:JAEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6141 SUNSET DR
Mailing Address - Street 2:SUITE #403
Mailing Address - City:SOUTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-5028
Mailing Address - Country:US
Mailing Address - Phone:305-669-5151
Mailing Address - Fax:305-669-2151
Practice Address - Street 1:6619 S DIXIE HWY
Practice Address - Street 2:PMB 272
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-7919
Practice Address - Country:US
Practice Address - Phone:305-669-5151
Practice Address - Fax:305-669-2151
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME38391174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL96800VOtherMEDICARE ID
FL041500600Medicaid
FLD28022Medicare UPIN
FL96800AMedicare ID - Type Unspecified