Provider Demographics
NPI:1023307832
Name:SAN JOSE, SERGIO (DO)
Entity type:Individual
Prefix:
First Name:SERGIO
Middle Name:
Last Name:SAN JOSE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2620 W 76TH ST APT 206
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-5649
Mailing Address - Country:US
Mailing Address - Phone:786-897-0578
Mailing Address - Fax:
Practice Address - Street 1:2620 W 76TH ST APT 206
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-5649
Practice Address - Country:US
Practice Address - Phone:786-897-0578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-01
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS12497207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease