Provider Demographics
NPI:1295043552
Name:PEDRO YLISASTIGUI. M.D.P.A.
Entity Type:Organization
Organization Name:PEDRO YLISASTIGUI. M.D.P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PEDRO
Authorized Official - Middle Name:
Authorized Official - Last Name:YLISASTIGUI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-369-9911
Mailing Address - Street 1:1150 LEE BLVD STE 4
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33936-4805
Mailing Address - Country:US
Mailing Address - Phone:239-369-9911
Mailing Address - Fax:
Practice Address - Street 1:1150 LEE BLVD STE 4
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33936-4805
Practice Address - Country:US
Practice Address - Phone:239-369-9911
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-21
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80423207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL259642300Medicaid
FLH27799Medicare UPIN
FL259642300Medicaid