Provider Demographics
NPI:1912932583
Name:DEJESUS, OTILIA (MD)
Entity type:Individual
Prefix:
First Name:OTILIA
Middle Name:
Last Name:DEJESUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14526 PLUMOSA DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-2222
Mailing Address - Country:US
Mailing Address - Phone:407-375-9139
Mailing Address - Fax:
Practice Address - Street 1:265 BROOKVIEW CENTRE WAY STE 400
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-4052
Practice Address - Country:US
Practice Address - Phone:800-342-2898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2024-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME105497207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001415901Medicaid
CT930001030Medicare PIN
CT001415901Medicaid