Provider Demographics
NPI:1831365972
Name:LOURDES L VIRTUSIO M D FAMILY PRACTICE CLINIC INC
Entity type:Organization
Organization Name:LOURDES L VIRTUSIO M D FAMILY PRACTICE CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LOURDES
Authorized Official - Middle Name:L
Authorized Official - Last Name:VIRTUSIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-432-4745
Mailing Address - Street 1:2102 TOWN STREET
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32526
Mailing Address - Country:US
Mailing Address - Phone:850-432-4745
Mailing Address - Fax:850-434-0395
Practice Address - Street 1:2102 TOWN STREET
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32526
Practice Address - Country:US
Practice Address - Phone:850-432-4745
Practice Address - Fax:850-434-0395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251986100Medicaid
G13009Medicare UPIN
K2292Medicare PIN