Provider Demographics
NPI:1720077308
Name:LLOSA, GUILLERMO JUAN (MD)
Entity Type:Individual
Prefix:
First Name:GUILLERMO
Middle Name:JUAN
Last Name:LLOSA
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 1:11400 N KENDALL DR
Mailing Address - Street 2:SUITE A211
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-1029
Mailing Address - Country:US
Mailing Address - Phone:305-274-2255
Mailing Address - Fax:305-274-2211
Practice Address - Street 1:11400 N KENDALL DR
Practice Address - Street 2:SUITE A211
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-1029
Practice Address - Country:US
Practice Address - Phone:305-274-2255
Practice Address - Fax:305-274-2211
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME00388852080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD63785Medicare UPIN