Basic Information
| Provider Information | |||||||||
| NPI: | 1629077318 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCACCABARROZZI | ||||||||
| FirstName: | LUIS | ||||||||
| MiddleName: | EDUARDO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, MPH | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SCACCABARROZZI | ||||||||
| OtherFirstName: | LUIS | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD, MPH | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6400 W NEWBERRY RD STE 109 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326054388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523324400 | ||||||||
| FaxNumber: | 3523320086 | ||||||||
| Practice Location | |||||||||
| Address1: | 6440 W NEWBERRY RD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326054381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523324400 | ||||||||
| FaxNumber: | 3523320086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2005 | ||||||||
| LastUpdateDate: | 11/03/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 2006001810 | MO | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | ME90127 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 269442500 | 05 | FL | MEDICAID | 1629077318 | 01 | FL | NPI | OTHER |