Basic Information
| Provider Information | |||||||||
| NPI: | 1912932583 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEJESUS JARQUIN | ||||||||
| FirstName: | OTILIA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2430 LINKWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | CLERMONT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347113506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073759139 | ||||||||
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| Practice Location | |||||||||
| Address1: | 265 BROOKVIEW CENTRE WAY STE 400 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379194052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003422898 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 09/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | ME105497 | FL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001415901 | 05 | CT | MEDICAID |