Healthcare Provider Details

I. General information

NPI: 1730272410
Provider Name (Legal Business Name): JOSE A LUIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 MAR WALT DR
FORT WALTON BEACH FL
32547-6707
US

IV. Provider business mailing address

1005 MAR WALT DR
FORT WALTON BEACH FL
32547-6707
US

V. Phone/Fax

Practice location:
  • Phone: 850-863-8203
  • Fax: 850-863-8118
Mailing address:
  • Phone: 850-863-8100
  • Fax: 850-863-8548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME164204
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: