Provider Demographics
NPI:1659489581
Name:CARRASCOSA, LUIS ALBERTO (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:ALBERTO
Last Name:CARRASCOSA
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:PO BOX 102222
Mailing Address - Street 2:ATTN CREDENTIALING DEPT
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2222
Mailing Address - Country:US
Mailing Address - Phone:239-274-8500
Mailing Address - Fax:
Practice Address - Street 1:4945 SW 49TH PL
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34474-9673
Practice Address - Country:US
Practice Address - Phone:352-237-9430
Practice Address - Fax:352-237-9698
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME991672085R0001X, 2085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014926721Medicaid
KY64074248Medicaid
KY0226911Medicare PIN