Provider Demographics
NPI:1962597211
Name:FRES, JOSE LUIS MAQUERA (OTR)
Entity type:Individual
Prefix:MR
First Name:JOSE LUIS
Middle Name:MAQUERA
Last Name:FRES
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13949 JACOBSON DR
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-1763
Mailing Address - Country:US
Mailing Address - Phone:813-766-3157
Mailing Address - Fax:
Practice Address - Street 1:17551 DALE MABRY HWY N
Practice Address - Street 2:SUITE #5
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33548-4521
Practice Address - Country:US
Practice Address - Phone:813-766-3157
Practice Address - Fax:813-920-9823
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT3218225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist