Provider Demographics
NPI:1740226794
Name:RUIZ, ESTEBAN ALFONSO (MD)
Entity Type:Individual
Prefix:
First Name:ESTEBAN
Middle Name:ALFONSO
Last Name:RUIZ
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 1:13910 FIVAY RD STE 15
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34667-7130
Mailing Address - Country:US
Mailing Address - Phone:727-484-6169
Mailing Address - Fax:727-844-5425
Practice Address - Street 1:13910 FIVAY RD STE 15
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-7130
Practice Address - Country:US
Practice Address - Phone:727-484-6169
Practice Address - Fax:727-484-6173
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-20
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME53805207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL07434OtherBC/BS
FL0527859OtherAETNA
FL1174793871OtherNPI GROUP
FL049101200Medicaid
FLC81647Medicare UPIN
FL1174793871OtherNPI GROUP