Provider Demographics
NPI:1417926833
Name:FANA, MIGUEL ANTONIO JR (MD)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:ANTONIO
Last Name:FANA
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:5400 PINEHURST DR
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34606-3833
Mailing Address - Country:US
Mailing Address - Phone:352-277-5348
Mailing Address - Fax:352-606-2857
Practice Address - Street 1:5798 38TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-1926
Practice Address - Country:US
Practice Address - Phone:727-384-0192
Practice Address - Fax:727-384-1500
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2023-09-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME80639207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL259988100Medicaid
FLE4429YMedicare PIN
H22163Medicare UPIN
FLH22163Medicare UPIN
E4429XMedicare PIN