Provider Demographics
NPI:1245402445
Name:PENTON, LUIS MIGUEL
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:MIGUEL
Last Name:PENTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3939 NW 7 STREET
Mailing Address - Street 2:STE #206
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126
Mailing Address - Country:US
Mailing Address - Phone:305-300-9629
Mailing Address - Fax:
Practice Address - Street 1:3939 NW 7TH ST STE 206
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-5552
Practice Address - Country:US
Practice Address - Phone:305-300-9629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-27
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91306173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH86120Medicare UPIN