Provider Demographics
NPI:1457318636
Name:ULLOA, LUIS S (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:S
Last Name:ULLOA
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 1:1094 MILITARY TRL
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-7021
Mailing Address - Country:US
Mailing Address - Phone:561-622-6111
Mailing Address - Fax:855-215-9930
Practice Address - Street 1:601 UNIVERSITY BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-2788
Practice Address - Country:US
Practice Address - Phone:561-627-7766
Practice Address - Fax:561-691-4865
Is Sole Proprietor?:No
Enumeration Date:2006-04-30
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME38283207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
27026Medicare ID - Type Unspecified
FLD85408Medicare UPIN