Provider Demographics
NPI:1376572594
Name:FANDOS, LUIS M (MD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:M
Last Name:FANDOS
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Gender:M
Credentials:MD
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Mailing Address - Street 1:11350 MCCORMICK RD
Mailing Address - Street 2:EXECUTIVE PLAZA 1, SUITE 501
Mailing Address - City:HUNT VALLEY
Mailing Address - State:MD
Mailing Address - Zip Code:21031
Mailing Address - Country:US
Mailing Address - Phone:410-329-1071
Mailing Address - Fax:410-329-1054
Practice Address - Street 1:500 W MAIN ST
Practice Address - Street 2:SUITE 116
Practice Address - City:BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11702
Practice Address - Country:US
Practice Address - Phone:631-422-6166
Practice Address - Fax:631-422-6266
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2021-06-18
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Provider Licenses
StateLicense IDTaxonomies
NY208260208VP0014X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01793255Medicaid
NY01793255Medicaid
NY32P38LL821Medicare PIN