Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207L00000X | Anesthesiologist | ME15151 | FL |
Y | 208D00000X | General Practice Physician | ME15151 | FL |
NPI | 1043754369 |
---|---|
Provider Name | Jaime Illel |
First Address | Boynton Beach, FL 33437-7515 |
Second Address | Boynton Beach, FL 33437-7515 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/12/2016 |
Last Update Date | 05/12/2016 |