Provider Demographics
NPI:1871102806
Name:SAN JORGE, EDUARDO
Entity type:Individual
Prefix:
First Name:EDUARDO
Middle Name:
Last Name:SAN JORGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7966 NW 162ND ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33016-6111
Mailing Address - Country:US
Mailing Address - Phone:786-683-9425
Mailing Address - Fax:
Practice Address - Street 1:14900 NW 79TH CT STE 101
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33016-5869
Practice Address - Country:US
Practice Address - Phone:305-821-0502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL35779225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist