Provider Demographics
NPI:1437711405
Name:PERSIA PAULINO, OSIRIS R (MD)
Entity type:Individual
Prefix:
First Name:OSIRIS
Middle Name:R
Last Name:PERSIA PAULINO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:OSIRIS
Other - Middle Name:R
Other - Last Name:PERSIA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-424-1900
Mailing Address - Fax:239-424-1904
Practice Address - Street 1:1138 COUNTRY CLUB BLVD
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-3027
Practice Address - Country:US
Practice Address - Phone:239-424-1900
Practice Address - Fax:239-424-1904
Is Sole Proprietor?:No
Enumeration Date:2019-06-30
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME154993208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114293200Medicaid