Basic Information
| Provider Information | |||||||||
| NPI: | 1982682779 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GARCIA | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3067 TAMIAMI TRL | ||||||||
| Address2: | STE 4 | ||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339526619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9419795602 | ||||||||
| FaxNumber: | 9417432121 | ||||||||
| Practice Location | |||||||||
| Address1: | 3067 TAMIAMI TRL | ||||||||
| Address2: | UNIT 3 | ||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339526601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9416131700 | ||||||||
| FaxNumber: | 9412583370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2006 | ||||||||
| LastUpdateDate: | 04/18/2017 | ||||||||
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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 | 207R00000X | ME0055898 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 063225200 | 05 | FL | MEDICAID | 4596887 | 01 | AETNA | OTHER | 09967 | 01 | BLUE CROSS BLUE SHIELD | OTHER | 110184271 | 01 | RAILROAD MEDICARE | OTHER |