Provider Demographics
NPI:1881747699
Name:MIRANDA-GENARO, LUIS S (MD)
Entity type:Individual
Prefix:DR
First Name:LUIS
Middle Name:S
Last Name:MIRANDA-GENARO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:LUIS
Other - Middle Name:S
Other - Last Name:MIRANDA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3105 MAGDALENE FOREST CT
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-2509
Mailing Address - Country:US
Mailing Address - Phone:813-960-2271
Mailing Address - Fax:813-960-2271
Practice Address - Street 1:6800 NORTH DALE MABRY HWY
Practice Address - Street 2:SUITE 198 B
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-3979
Practice Address - Country:US
Practice Address - Phone:813-884-1944
Practice Address - Fax:813-884-1955
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME56636207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD08265Medicare UPIN
FL10915Medicare PIN