Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | ME103629 | FL |
N | 207U00000X | Nuclear Medicine Specialist | ME103629 | FL |
NPI | 1710203435 |
---|---|
Provider Name | Jesse Balseiro |
First Address | Jacksonville, FL 32256-5004 |
Second Address | Jacksonville, FL 32216-0986 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/04/2010 |
Last Update Date | 12/02/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
E37237 | (02) | LA |