Provider Demographics
NPI:1376936534
Name:CARMONA, LUIS
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:
Last Name:CARMONA
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 1:12821 SW 43RD DR APT 131
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-4119
Mailing Address - Country:US
Mailing Address - Phone:305-763-7176
Mailing Address - Fax:
Practice Address - Street 1:3431 SW 107TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-3632
Practice Address - Country:US
Practice Address - Phone:305-551-7222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-12
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAI117172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker