Provider Demographics
NPI:1619418829
Name:MEDRANO, LUIS ANTONIO (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:ANTONIO
Last Name:MEDRANO
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 1:167 W 23RD ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33010-2211
Mailing Address - Country:US
Mailing Address - Phone:305-823-3312
Mailing Address - Fax:786-360-2327
Practice Address - Street 1:20841 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33189-2217
Practice Address - Country:US
Practice Address - Phone:058-233-3123
Practice Address - Fax:786-360-2327
Is Sole Proprietor?:No
Enumeration Date:2017-03-20
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME144164207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program