Provider Demographics
NPI:1013108984
Name:LOURDES LORETO MD PA
Entity Type:Organization
Organization Name:LOURDES LORETO MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LOURDES
Authorized Official - Middle Name:
Authorized Official - Last Name:LORETO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-877-3902
Mailing Address - Street 1:4710 N HABANA AVE
Mailing Address - Street 2:202
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614
Mailing Address - Country:US
Mailing Address - Phone:813-877-3902
Mailing Address - Fax:813-877-3807
Practice Address - Street 1:4710 N HABANA AVE
Practice Address - Street 2:202
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614
Practice Address - Country:US
Practice Address - Phone:813-877-3902
Practice Address - Fax:813-877-3807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-06
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME29045207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL057966100Medicaid
FL29972OtherBLUE CROSS BLUE SHIELD
FL407112745OtherRAILROAD MEDICARE
D53814Medicare UPIN
FLAG419Medicare PIN