Provider Demographics
NPI:1578925558
Name:CALVO FRAGACHAN, LUIS MIGUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:MIGUEL
Last Name:CALVO FRAGACHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:LUIS
Other - Middle Name:M
Other - Last Name:CALVO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:38135 MARKET SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33542-7505
Mailing Address - Country:US
Mailing Address - Phone:352-567-0188
Mailing Address - Fax:813-355-5101
Practice Address - Street 1:36763 EILAND BLVD STE 102
Practice Address - Street 2:
Practice Address - City:ZEPHYRHILLS
Practice Address - State:FL
Practice Address - Zip Code:33542-0600
Practice Address - Country:US
Practice Address - Phone:813-778-0454
Practice Address - Fax:813-377-1699
Is Sole Proprietor?:No
Enumeration Date:2016-03-28
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101267924207R00000X
FLME142788207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL121356000Medicaid