Provider Demographics
NPI:1639105661
Name:LOZADA PEREZ, YANITT GRISEL (MD)
Entity Type:Individual
Prefix:MRS
First Name:YANITT
Middle Name:GRISEL
Last Name:LOZADA PEREZ
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 1:5061 CAMBRY LN
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-7554
Mailing Address - Country:US
Mailing Address - Phone:863-802-9107
Mailing Address - Fax:863-802-9107
Practice Address - Street 1:204 E PALMETTO ST
Practice Address - Street 2:
Practice Address - City:WAUCHULA
Practice Address - State:FL
Practice Address - Zip Code:33873-2732
Practice Address - Country:US
Practice Address - Phone:863-773-2111
Practice Address - Fax:863-773-3429
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR16,052208D00000X
FLACN282208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000350300Medicaid