Provider Demographics
NPI:1790411858
Name:LUIS, EDUARDO JOSE
Entity Type:Individual
Prefix:MR
First Name:EDUARDO
Middle Name:JOSE
Last Name:LUIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12535 S DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:PINECREST
Mailing Address - State:FL
Mailing Address - Zip Code:33156-5930
Mailing Address - Country:US
Mailing Address - Phone:786-678-0601
Mailing Address - Fax:
Practice Address - Street 1:16783 SW 96TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33196-4760
Practice Address - Country:US
Practice Address - Phone:786-678-0601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-29
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11021034363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily