Provider Demographics
NPI:1154707610
Name:PRIETO, JESUS
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:
Last Name:PRIETO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:939 PARK MANOR DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-6744
Mailing Address - Country:US
Mailing Address - Phone:407-432-6785
Mailing Address - Fax:407-897-7452
Practice Address - Street 1:939 PARK MANOR DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32825-6744
Practice Address - Country:US
Practice Address - Phone:407-432-6785
Practice Address - Fax:407-897-7452
Is Sole Proprietor?:No
Enumeration Date:2015-08-07
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12312172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008511900Medicaid