Provider Demographics
NPI:1700087251
Name:LUIS, ALEJANDRO JOSE (MD)
Entity Type:Individual
Prefix:
First Name:ALEJANDRO
Middle Name:JOSE
Last Name:LUIS
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:PO BOX 3413
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-3413
Mailing Address - Country:US
Mailing Address - Phone:850-864-4033
Mailing Address - Fax:850-864-4076
Practice Address - Street 1:1703 LEWIS TURNER BLVD
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1221
Practice Address - Country:US
Practice Address - Phone:850-864-4033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL 29082208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1530217Medicaid
SC290820Medicaid
TN103I026127Medicare PIN
SCSC17595774Medicare PIN