Provider Demographics
NPI:1770576746
Name:PALOMINO-PITOCCHI, LOURDES (MD)
Entity type:Individual
Prefix:
First Name:LOURDES
Middle Name:
Last Name:PALOMINO-PITOCCHI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3074 AMELLIA DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-5702
Mailing Address - Country:US
Mailing Address - Phone:904-731-9367
Mailing Address - Fax:
Practice Address - Street 1:274 3RD AVE S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-6727
Practice Address - Country:US
Practice Address - Phone:904-249-3373
Practice Address - Fax:904-249-3375
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME62355208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL372070500Medicaid
FLE99434Medicare UPIN