Provider Demographics
NPI:1710974233
Name:PLAZA-LUCIANO, MANUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:
Last Name:PLAZA-LUCIANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MANUEL
Other - Middle Name:
Other - Last Name:PLAZA-LUCIANO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2583 S VOLUSIA AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-9129
Mailing Address - Country:US
Mailing Address - Phone:386-456-2080
Mailing Address - Fax:
Practice Address - Street 1:2583 S VOLUSIA AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-9129
Practice Address - Country:US
Practice Address - Phone:386-456-2080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR10857207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
8HM846Medicare UPIN