Provider Demographics
NPI:1104966639
Name:JUSTINO SILVESTRE MD PA
Entity type:Organization
Organization Name:JUSTINO SILVESTRE MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JUSTINO
Authorized Official - Middle Name:
Authorized Official - Last Name:SILVESTRE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-255-9815
Mailing Address - Street 1:PO BOX 495550
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33949-5550
Mailing Address - Country:US
Mailing Address - Phone:941-255-9815
Mailing Address - Fax:
Practice Address - Street 1:3524 TAMIAMI TRAIL
Practice Address - Street 2:SUITE D
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948
Practice Address - Country:US
Practice Address - Phone:941-255-9815
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME67570207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252914900Medicaid
FLDQ723AMedicare PIN
FL252914900Medicaid