Provider Demographics
NPI:1881813079
Name:MADURO, LUIS GASPAR JR (MD)
Entity type:Individual
Prefix:DR
First Name:LUIS
Middle Name:GASPAR
Last Name:MADURO
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:18161 W 13 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-1113
Mailing Address - Country:US
Mailing Address - Phone:248-480-4183
Mailing Address - Fax:
Practice Address - Street 1:18161 W 13 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076
Practice Address - Country:US
Practice Address - Phone:248-480-4183
Practice Address - Fax:248-792-2631
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PR12074207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLI33348Medicare UPIN