Provider Demographics
NPI:1841297942
Name:CASANOVA, LUIS A (MD)
Entity type:Individual
Prefix:DR
First Name:LUIS
Middle Name:A
Last Name:CASANOVA
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 495790
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33949-5790
Mailing Address - Country:US
Mailing Address - Phone:941-883-3313
Mailing Address - Fax:941-883-3320
Practice Address - Street 1:3508 TAMIAMI TRL
Practice Address - Street 2:SUITE C
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-8160
Practice Address - Country:US
Practice Address - Phone:941-883-3313
Practice Address - Fax:941-883-3320
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0053174207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL07449OtherBC/BS INDIVIDUAL
FL049029600Medicaid
FL2492651001OtherCIGNA
FL34749OtherBC/BS GROUP NUMBER
FL34749OtherBC/BS GROUP NUMBER
FL34749Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER