Provider Demographics
NPI:1477610715
Name:YLISASTIGUI, PEDRO P (MD)
Entity Type:Individual
Prefix:
First Name:PEDRO
Middle Name:P
Last Name:YLISASTIGUI
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 1:1150 LEE BLVD STE 4
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33936-4805
Mailing Address - Country:US
Mailing Address - Phone:239-369-9911
Mailing Address - Fax:239-369-9901
Practice Address - Street 1:1150 LEE BLVD STE 4
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33936-4805
Practice Address - Country:US
Practice Address - Phone:239-369-9911
Practice Address - Fax:239-369-9901
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80423207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL259642300Medicaid
FL51728Medicare ID - Type Unspecified