Provider Demographics
NPI:1548646334
Name:MARIA LOURDES P BURGOS , MD
Entity type:Organization
Organization Name:MARIA LOURDES P BURGOS , MD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIA LOURDES
Authorized Official - Middle Name:P
Authorized Official - Last Name:BURGOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-255-3688
Mailing Address - Street 1:820 E ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-4248
Mailing Address - Country:US
Mailing Address - Phone:352-589-1999
Mailing Address - Fax:352-589-5145
Practice Address - Street 1:820 E ORANGE AVE
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-4248
Practice Address - Country:US
Practice Address - Phone:352-589-1999
Practice Address - Fax:352-589-5145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 054370208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL037046100Medicaid