Provider Demographics
NPI:1225092182
Name:CARRERO-RUIZ, LOURDES (MD)
Entity Type:Individual
Prefix:
First Name:LOURDES
Middle Name:
Last Name:CARRERO-RUIZ
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 1:3487 BROADWAY AVENUE
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-7213
Mailing Address - Country:US
Mailing Address - Phone:239-334-9555
Mailing Address - Fax:239-334-2832
Practice Address - Street 1:3487 BROADWAY AVENUE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-7213
Practice Address - Country:US
Practice Address - Phone:239-334-9555
Practice Address - Fax:239-334-2832
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR10482208D00000X
FLACN117208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003953400Medicaid
FLIZ052XOtherMEDICARE