Provider Demographics
NPI:1508045774
Name:LORETO, LOURDES U (MD)
Entity Type:Individual
Prefix:DR
First Name:LOURDES
Middle Name:U
Last Name:LORETO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4710 N HABANA AVENUE
Mailing Address - Street 2:STE 202
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-7146
Mailing Address - Country:US
Mailing Address - Phone:813-877-3902
Mailing Address - Fax:813-877-3807
Practice Address - Street 1:4710 N HABANA AVENUE
Practice Address - Street 2:STE 202
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-7146
Practice Address - Country:US
Practice Address - Phone:813-877-3902
Practice Address - Fax:813-877-3807
Is Sole Proprietor?:No
Enumeration Date:2007-10-24
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME29045207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL057966100Medicaid
FL407112745OtherRAILROAD MEDICARE
FL407112745OtherRAILROAD MEDICARE
FL29972ZMedicare PIN