Provider Demographics
NPI:1700875739
Name:LOGRONO, LUIS A (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:A
Last Name:LOGRONO
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 1:18964 DALE MABRY HWY N
Mailing Address - Street 2:STE 101
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33548-4913
Mailing Address - Country:US
Mailing Address - Phone:813-948-2107
Mailing Address - Fax:813-948-2790
Practice Address - Street 1:18964 DALE MABRY HWY N
Practice Address - Street 2:SUITE 101
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33548-4913
Practice Address - Country:US
Practice Address - Phone:813-948-2107
Practice Address - Fax:813-948-2790
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME67430207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL379686800Medicaid
FL33310OtherBLUE SHIELD PALM HARBOR MEDICAL
FL9326165OtherAETNA GROUP #
FL5359105OtherAETNA
FL33864OtherBLUE SHIELD
FL9326165OtherAETNA GROUP #
FL33864OtherBLUE SHIELD