Basic Information
Provider Information | |||||||||
NPI: | 1518166255 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | IRIZARRY | ||||||||
FirstName: | LUISA | ||||||||
MiddleName: | M. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1005 | ||||||||
Address2: |   | ||||||||
City: | LAKE CITY | ||||||||
State: | FL | ||||||||
PostalCode: | 320561005 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3867553016 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 619 S MARION AVE | ||||||||
Address2: |   | ||||||||
City: | LAKE CITY | ||||||||
State: | FL | ||||||||
PostalCode: | 320255808 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3867553016 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2007 | ||||||||
LastUpdateDate: | 07/12/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246QM0706X |   |   | Y |   | Technologists, Technicians & Other Technical Service Providers | Spec/Tech, Pathology | Medical Technologist |
No ID Information.