Healthcare Provider Details

I. General information

NPI: 1841297942
Provider Name (Legal Business Name): LUIS A CASANOVA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 09/09/2020
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3508 TAMIAMI TRL SUITE C
PORT CHARLOTTE FL
33952-8160
US

IV. Provider business mailing address

PO BOX 495790
PORT CHARLOTTE FL
33949-5790
US

V. Phone/Fax

Practice location:
  • Phone: 941-883-3313
  • Fax: 941-883-3320
Mailing address:
  • Phone: 941-883-3313
  • Fax: 941-883-3320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberME0053174
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: