Provider Demographics
NPI:1194110528
Name:PUERTAS, JUAN M (DO)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:M
Last Name:PUERTAS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7825 SW 165TH ST
Mailing Address - Street 2:
Mailing Address - City:PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-3742
Mailing Address - Country:US
Mailing Address - Phone:614-401-7470
Mailing Address - Fax:
Practice Address - Street 1:550 1ST AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6402
Practice Address - Country:US
Practice Address - Phone:212-263-5230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-02
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS173862085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110205800Medicaid