Basic Information
| Provider Information | |||||||||
| NPI: | 1841297942 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CASANOVA | ||||||||
| FirstName: | LUIS | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 495790 | ||||||||
| Address2: | |||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339495790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9418833313 | ||||||||
| FaxNumber: | 9418833320 | ||||||||
| Practice Location | |||||||||
| Address1: | 3508 TAMIAMI TRL | ||||||||
| Address2: | SUITE C | ||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339528160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9418833313 | ||||||||
| FaxNumber: | 9418833320 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2005 | ||||||||
| LastUpdateDate: | 09/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | ME0053174 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 07449 | 01 | FL | BC/BS INDIVIDUAL | OTHER | 049029600 | 05 | FL | MEDICAID | 2492651001 | 01 | FL | CIGNA | OTHER | 34749 | 01 | FL | BC/BS GROUP NUMBER | OTHER |