Basic Information
| Provider Information | |||||||||
| NPI: | 1952516742 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FREYRE-CUBANO | ||||||||
| FirstName: | JAQUELINE | ||||||||
| MiddleName: | MARIETTE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 844 N THORNTON AVE | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328034003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073986470 | ||||||||
| FaxNumber: | 4073986872 | ||||||||
| Practice Location | |||||||||
| Address1: | 844 N THORNTON AVE | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328034003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073986470 | ||||||||
| FaxNumber: | 4073986872 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2007 | ||||||||
| LastUpdateDate: | 02/28/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME98628 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 278293600 | 05 | FL | MEDICAID |