Healthcare Provider Details

I. General information

NPI: 1245402445
Provider Name (Legal Business Name): LUIS MIGUEL PENTON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2008
Last Update Date: 03/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3939 NW 7TH ST STE 206
MIAMI FL
33126-5552
US

IV. Provider business mailing address

3939 NW 7 STREET STE #206
MIAMI FL
33126
US

V. Phone/Fax

Practice location:
  • Phone: 305-300-9629
  • Fax:
Mailing address:
  • Phone: 305-300-9629
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberME91306
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: