Provider Demographics
NPI:1538423967
Name:LUNA RUSSO, MIGUEL A (MD)
Entity type:Individual
Prefix:
First Name:MIGUEL
Middle Name:A
Last Name:LUNA RUSSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4631 N CONGRESS AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-3209
Mailing Address - Country:US
Mailing Address - Phone:561-764-2750
Mailing Address - Fax:
Practice Address - Street 1:4631 N CONGRESS AVE STE 100
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-3209
Practice Address - Country:US
Practice Address - Phone:561-764-2750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-29
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ23780207V00000X
OH35.136534207VF0040X, 207VG0400X
FLME163514207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyUrogynecology and Reconstructive Pelvic Surgery
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology