MEDICARE: LOURDES CARRERO-RUIZ M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	10482	PR
2	208D00000X	General Practice Physician	ACN117	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	IZ052X	OTHER	FL	MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225092182
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOURDES CARRERO-RUIZ M.D.

Provider Business Mailing Address
First Line	:	3487 BROADWAY AVENUE
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33901-7213
Country	:	US
Telephone Number	:	239-334-9555
Fax Number	:	239-334-2832

Provider Business Practice Location Address
First Line	:	3487 BROADWAY AVENUE
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33901-7213
Country	:	US
Telephone Number	:	239-334-9555
Fax Number	:	239-334-2832

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/17/2006
Last Update Date	:	12/02/2020

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