Provider Demographics
NPI:1427047836
Name:PROENZA, JOSE LUIS (MD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:LUIS
Last Name:PROENZA
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 1:210 JUPITER LAKES BLVD
Mailing Address - Street 2:BUILDING 3000 SUITE 106
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-7191
Mailing Address - Country:US
Mailing Address - Phone:561-746-6300
Mailing Address - Fax:561-746-6376
Practice Address - Street 1:210 JUPITER LAKES BLVD
Practice Address - Street 2:BUILDING 3000 SUITE 106
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-7191
Practice Address - Country:US
Practice Address - Phone:561-746-6300
Practice Address - Fax:561-746-6376
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME62386207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL26491OtherBLUE CROSS BLUE SHIELD
FL26491OtherBLUE CROSS BLUE SHIELD
F96631Medicare UPIN