Provider Demographics
NPI:1992736797
Name:LUIS-JORGE, JUAN C (MD)
Entity type:Individual
Prefix:DR
First Name:JUAN
Middle Name:C
Last Name:LUIS-JORGE
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 1:4114 ALHAMBRA DR W
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-6017
Mailing Address - Country:US
Mailing Address - Phone:904-398-9951
Mailing Address - Fax:904-398-9875
Practice Address - Street 1:4933 UNIVERSITY BLVD W
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-5935
Practice Address - Country:US
Practice Address - Phone:904-733-7800
Practice Address - Fax:904-419-4888
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0052228174400000X
FLME522282085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL049288400Medicaid
FL07194Medicare ID - Type Unspecified
FL049288400Medicaid