Basic Information
| Provider Information | |||||||||
| NPI: | 1639103609 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ATIENZA | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | TIA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ATIENZA | ||||||||
| OtherFirstName: | WILFRED JASON | ||||||||
| OtherMiddleName: | TIA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 32 W GORE ST | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328061134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076496151 | ||||||||
| FaxNumber: | 3219436658 | ||||||||
| Practice Location | |||||||||
| Address1: | 32 W GORE ST | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328061134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076496151 | ||||||||
| FaxNumber: | 3219436658 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 11/15/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | A86516 | CA | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | ME 116489 | FL | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 009173800 | 05 | FL | MEDICAID | ME116489 | 01 | FL | MEDICAL LICENSE | OTHER |