Basic Information
| Provider Information | |||||||||
| NPI: | 1922083948 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PICHARDO | ||||||||
| FirstName: | JESUS | ||||||||
| MiddleName: | RAFAEL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PICHARDO | ||||||||
| OtherFirstName: | JESUS | ||||||||
| OtherMiddleName: | R | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1130 S SEMORAN BLVD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328071457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073821376 | ||||||||
| FaxNumber: | 3212353232 | ||||||||
| Practice Location | |||||||||
| Address1: | 1130 S SEMORAN BLVD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328071457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073821376 | ||||||||
| FaxNumber: | 3212353232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2005 | ||||||||
| LastUpdateDate: | 04/19/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | ACN320 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.