Basic Information
| Provider Information | |||||||||
| NPI: | 1023087707 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LLANES | ||||||||
| FirstName: | JESUS | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4960 SW 72ND AV | ||||||||
| Address2: | SUITE 406 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331555506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056625200 | ||||||||
| FaxNumber: | 3052847940 | ||||||||
| Practice Location | |||||||||
| Address1: | 4960 SW 72ND AVE | ||||||||
| Address2: | SUITE 406 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331555544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056625200 | ||||||||
| FaxNumber: | 3052847940 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 09/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 49076 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 49076 | 01 | FL | FLORIDA MEDICAL LICENCE | OTHER | 049965000 | 05 | FL | MEDICAID |