Basic Information
| Provider Information | |||||||||
| NPI: | 1497757645 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEJESUS | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 32 W GORE ST STE 204 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328061134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076496884 | ||||||||
| FaxNumber: | 4072457059 | ||||||||
| Practice Location | |||||||||
| Address1: | 32 W GORE ST STE 204 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328061134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076496884 | ||||||||
| FaxNumber: | 4072457059 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2005 | ||||||||
| LastUpdateDate: | 08/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208C00000X | ME78134 | FL | Y | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
ID Information
| ID | Type | State | Issuer | Description | 259597400 | 05 | FL | MEDICAID |