Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207T00000X | Neurosurgeon | ME0041511 | FL |
NPI | 1093736639 |
---|---|
Provider Name | Kenneth Maliq Louis |
First Address | Orlando, FL 32891-7770 |
Second Address | Tampa, FL 33606-3603 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/07/2006 |
Last Update Date | 03/01/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
068356600 | (05) | FL |
30546 | BLUE CROSS BLUE SHIELD (01) | FL |
D54031 | (02) | FL |