Provider Demographics
NPI:1225076797
Name:DUHARTE VIDAURRE, LUIS ANGEL (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:ANGEL
Last Name:DUHARTE VIDAURRE
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 1:130 MEDICAL CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33870-5463
Mailing Address - Country:US
Mailing Address - Phone:863-314-0004
Mailing Address - Fax:863-304-8284
Practice Address - Street 1:130 MEDICAL CENTER AVE
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-5463
Practice Address - Country:US
Practice Address - Phone:863-314-0004
Practice Address - Fax:863-304-8284
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME95160207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00316333OtherRAILROAD MEDICARE
FL52551OtherBCBS
FL023676600Medicaid
I54146Medicare UPIN
P00316333OtherRAILROAD MEDICARE
FL52551ZMedicare PIN