Provider Demographics
NPI:1699780106
Name:TOLOSA, JORGE ENRIQUE (MD, MSCE)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:ENRIQUE
Last Name:TOLOSA
Suffix:
Gender:M
Credentials:MD, MSCE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 OSTRUM ST STE 303
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN HILL
Mailing Address - State:PA
Mailing Address - Zip Code:18015-1152
Mailing Address - Country:US
Mailing Address - Phone:484-526-3900
Mailing Address - Fax:866-410-7401
Practice Address - Street 1:701 OSTRUM ST STE 303
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILL
Practice Address - State:PA
Practice Address - Zip Code:18015
Practice Address - Country:US
Practice Address - Phone:503-494-2101
Practice Address - Fax:866-410-7401
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD25459207V00000X, 207VM0101X
WAMD00048485207V00000X, 207VM0101X
PAMD065192L207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022790Medicaid
E21752Medicare UPIN