Basic Information
Provider Information | |||||||||
NPI: | 1497189971 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TORRES | ||||||||
FirstName: | JORGE | ||||||||
MiddleName: | LUIS | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 737 S SEMORAN BLVD | ||||||||
Address2: |   | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328073121 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3212474960 | ||||||||
FaxNumber: | 8339630116 | ||||||||
Practice Location | |||||||||
Address1: | 737 S SEMORAN BLVD | ||||||||
Address2: |   | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328073121 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3212474960 | ||||||||
FaxNumber: | 8339630116 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/03/2013 | ||||||||
LastUpdateDate: | 11/01/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/03/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 19194 | PR | N |   | Allopathic & Osteopathic Physicians | General Practice |   | 208D00000X | ME132746 | FL | Y |   | Allopathic & Osteopathic Physicians | General Practice |   |
ID Information
ID | Type | State | Issuer | Description | FT5666447 | 01 | FL | DEA | OTHER | 25137000 | 05 | FL |   | MEDICAID | ME132746 | 01 | FL | MEDICAL LICENSE | OTHER |