Provider Demographics
NPI:1659452332
Name:PRO LANDAZURI, JOSE MIGUEL (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:MIGUEL
Last Name:PRO LANDAZURI
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 1:5106 N ARMENIA AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5106 N ARMENIA AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603
Practice Address - Country:US
Practice Address - Phone:813-877-0423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL32959207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL011912200Medicaid
FL79479WMedicare PIN