Basic Information
| Provider Information | |||||||||
| NPI: | 1609180249 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUSANCAREZ | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | ANTONIO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SANTIAGO PEREZ | ||||||||
| OtherFirstName: | JOSE | ||||||||
| OtherMiddleName: | ANTONIO | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3832 W HUMPHREY ST | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336141955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8134404420 | ||||||||
| FaxNumber: | 8135020290 | ||||||||
| Practice Location | |||||||||
| Address1: | 1060 W 49TH ST | ||||||||
| Address2: | |||||||||
| City: | HIALEAH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330123322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8446654827 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2010 | ||||||||
| LastUpdateDate: | 11/06/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0401X | ACN485 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine | 208D00000X | ACN485 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.