Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0204X | Pediatric Emergency Doctor | ME25395 | FL |
NPI | 1225141229 |
---|---|
Provider Name | Tomas Jacome |
First Address | Fort Myers, FL 33902-2147 |
Second Address | Fort Myers, FL 33908 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/08/2006 |
Last Update Date | 23/05/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
214084 | AMERIGROUP (01) | FL |
226495 | AVMED (01) | FL |
250936900 | (05) | FL |
55061 | BCBS (01) | FL |
D56708 | (02) | FL |