Provider Demographics
NPI:1003116286
Name:MOLINA, LUIS MARIO (MA)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:MARIO
Last Name:MOLINA
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15736 SW 50TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33185-5035
Mailing Address - Country:US
Mailing Address - Phone:786-294-2772
Mailing Address - Fax:
Practice Address - Street 1:15736 SW 50TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33185-5035
Practice Address - Country:US
Practice Address - Phone:786-294-2772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-22
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11003688207Q00000X
FLMA51731225700000X
FLAPRN11003668363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAPRN11003688OtherADVANCE PRACTICE REGISTERED NURSE
FLRN9396435OtherREGISTERED NURSE