Basic Information
| Provider Information | |||||||||
| NPI: | 1588293492 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AQUINO | ||||||||
| FirstName: | JESSE | ||||||||
| MiddleName: | ALEXANDER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 REDMOND RD NW | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301651415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068023025 | ||||||||
| FaxNumber: | 7062951184 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 REDMOND RD NW | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301651415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068023025 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2020 | ||||||||
| LastUpdateDate: | 05/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 11841 | GA | N | 193200000X MULTI-SPECIALTY GROUP | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 91262 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | FA1472214 | 01 | DEA | OTHER |