Provider Demographics
NPI:1871536615
Name:MENENDEZ, LUIS TERRY (MD)
Entity type:Individual
Prefix:DR
First Name:LUIS
Middle Name:TERRY
Last Name:MENENDEZ
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 1:3011 W SWANN AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-4059
Mailing Address - Country:US
Mailing Address - Phone:813-879-8436
Mailing Address - Fax:813-878-2405
Practice Address - Street 1:3011 W SWANN AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-4059
Practice Address - Country:US
Practice Address - Phone:813-879-8436
Practice Address - Fax:813-878-2405
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24434207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3211253OtherAETNA
FL204969400Medicaid
FL406073185OtherRAILROAD MEDICARE
FL406073185OtherRAILROAD MEDICARE