Provider Demographics
NPI:1962587147
Name:OSPINA, LUIS FERNANDO (MD)
Entity type:Individual
Prefix:DR
First Name:LUIS
Middle Name:FERNANDO
Last Name:OSPINA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:17412 W 13 MILE RD
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-5439
Mailing Address - Country:US
Mailing Address - Phone:248-258-8740
Mailing Address - Fax:248-258-9329
Practice Address - Street 1:17412 W 13 MILE RD
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:MI
Practice Address - Zip Code:48025-5439
Practice Address - Country:US
Practice Address - Phone:248-258-8740
Practice Address - Fax:248-258-9329
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301034402207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1962587147OtherBLUE CROSS BLUE SHIELD
MI2098391Medicaid
B43129Medicare UPIN
MI2098391Medicaid