Basic Information
| Provider Information | |||||||||
| NPI: | 1730138785 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TANFULLA | ||||||||
| FirstName: | LUCIANO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TANFULLA | ||||||||
| OtherFirstName: | LUCIANO | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1600 S ANDREWS AVE | ||||||||
| Address2: | 4TH FLR NICU | ||||||||
| City: | FT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333162510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543555870 | ||||||||
| FaxNumber: | 9543555872 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 S ANDREWS AVE | ||||||||
| Address2: | 4TH FLR NICU | ||||||||
| City: | FT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333162510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543555870 | ||||||||
| FaxNumber: | 9543555872 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 12/12/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | ME 56384 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 251451600 | 05 | FL | MEDICAID |