Provider Demographics
NPI:1114038023
Name:HUMARAN, ANSELMO HUMBERTO (MD)
Entity Type:Individual
Prefix:
First Name:ANSELMO
Middle Name:HUMBERTO
Last Name:HUMARAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11474 QUAIL ROOST DR
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33157-6575
Mailing Address - Country:US
Mailing Address - Phone:305-232-2066
Mailing Address - Fax:305-232-2089
Practice Address - Street 1:11474 QUAIL ROOST DR
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33157-6575
Practice Address - Country:US
Practice Address - Phone:305-232-2066
Practice Address - Fax:305-232-2089
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME41680208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL067320000Medicaid
FL96178OtherMEDICARE ID
FLD27957Medicare UPIN