Provider Demographics
NPI:1972607349
Name:BURGOS, MARIA LOURDES P
Entity Type:Individual
Prefix:
First Name:MARIA LOURDES
Middle Name:P
Last Name:BURGOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MA LOURDES
Other - Middle Name:P
Other - Last Name:BURGOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:820 E ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-4248
Mailing Address - Country:US
Mailing Address - Phone:352-589-1999
Mailing Address - Fax:352-589-5145
Practice Address - Street 1:820 E ORANGE AVE
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-4248
Practice Address - Country:US
Practice Address - Phone:352-589-1999
Practice Address - Fax:352-589-5145
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0054370208000000X
FLME54370207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPD066OtherPEDICARE
FL09722OtherBLUE CROSS BLUE SHIELD
FL1200629OtherUNITED HEALTHCARE
FL037046100Medicaid