Provider Demographics
NPI:1386684967
Name:LIZARDO, MIGUEL (MD)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:
Last Name:LIZARDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12485 HITCHING ST
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-3852
Mailing Address - Country:US
Mailing Address - Phone:508-904-7243
Mailing Address - Fax:
Practice Address - Street 1:12470 TELECOM DR STE 300W
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33637-0904
Practice Address - Country:US
Practice Address - Phone:813-871-8183
Practice Address - Fax:813-871-8184
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA218399207R00000X
FLME135155207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2134217Medicaid
MA2134217Medicaid
MAA4016801Medicare PIN