Provider Demographics
NPI:1053389445
Name:DOPICO, JORGE L (DPM)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:L
Last Name:DOPICO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 1ST ST N
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-4129
Mailing Address - Country:US
Mailing Address - Phone:863-294-0670
Mailing Address - Fax:863-298-3200
Practice Address - Street 1:601 1ST ST N
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4129
Practice Address - Country:US
Practice Address - Phone:863-294-0670
Practice Address - Fax:863-298-3200
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-10
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2742213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL390454700Medicaid
FL480027080OtherMEDICARE ID/RRM PIN
FL390454700Medicaid
FL480027080OtherMEDICARE ID/RRM PIN