Provider Demographics
NPI:1164495289
Name:MEDEROS-LEZCANO, MIRTA M (MD)
Entity Type:Individual
Prefix:
First Name:MIRTA
Middle Name:M
Last Name:MEDEROS-LEZCANO
Suffix:
Gender:F
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:PO BOX 817737
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33081-1737
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7700 W SUNRISE BLVD # 200
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33322-4113
Practice Address - Country:US
Practice Address - Phone:954-838-2371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME64316207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL262363300Medicaid
FL27049WMedicare ID - Type Unspecified
FL27049XMedicare ID - Type Unspecified