Basic Information
| Provider Information | |||||||||
| NPI: | 1760424519 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIFUENTES | ||||||||
| FirstName: | JORGE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 951 COMMERCE PKWY STE 101 | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458044040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199984575 | ||||||||
| FaxNumber: | 4199984586 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 BELLEFONTAINE AVE | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458042800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192283335 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 02/13/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 35055919 | OH | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 000000175871 | 01 | OH | ANTHEM | OTHER | 050077131 | 01 | OH | RAILROAD MEDICARE | OTHER | 0788876 | 05 | OH | MEDICAID |