Basic Information
| Provider Information | |||||||||
| NPI: | 1518925742 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AGSALUD | ||||||||
| FirstName: | JAYMIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 S FISKE BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329554306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3214341771 | ||||||||
| FaxNumber: | 3219517408 | ||||||||
| Practice Location | |||||||||
| Address1: | 1350 S HICKORY ST | ||||||||
| Address2: | HRMC/HOSPITALIST PROGRAM | ||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329013224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3214341771 | ||||||||
| FaxNumber: | 3214341774 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 07/28/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 226613 | MA | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | ME102005 | FL | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | ME102005 | 01 | FL | LICENSE | OTHER | 000589700 | 05 | FL | MEDICAID |