Provider Demographics
NPI:1306057484
Name:JACOB-AMPUERO, MARIE-PAULE L (MD)
Entity type:Individual
Prefix:DR
First Name:MARIE-PAULE
Middle Name:L
Last Name:JACOB-AMPUERO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARIE-PAULE
Other - Middle Name:L
Other - Last Name:JACOB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 741087
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-1087
Mailing Address - Country:US
Mailing Address - Phone:954-777-0018
Mailing Address - Fax:866-262-5507
Practice Address - Street 1:7201 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-2913
Practice Address - Country:US
Practice Address - Phone:954-724-6197
Practice Address - Fax:954-724-6444
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251072207ZP0105X
FLME98156207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400000706Medicare PIN