Basic Information
| Provider Information | |||||||||
| NPI: | 1467885640 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAZA SEGURA | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | GUILLERMO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 121 S ORANGE AVE STE 940 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328013234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3213326947 | ||||||||
| FaxNumber: | 4076589688 | ||||||||
| Practice Location | |||||||||
| Address1: | 810 N NOWELL STREET | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32808 | ||||||||
| CountryCode: | UM | ||||||||
| TelephoneNumber: | 4072909556 | ||||||||
| FaxNumber: | 4072909505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2013 | ||||||||
| LastUpdateDate: | 04/26/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 18555 | PR | N | Allopathic & Osteopathic Physicians | General Practice | 208D00000X | ACN545 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 012319300 | 05 | FL | MEDICAID |