Provider Demographics
NPI:1053355297
Name:OQUENDO, LUCIANO III (MD)
Entity type:Individual
Prefix:
First Name:LUCIANO
Middle Name:
Last Name:OQUENDO
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:LUCIANO
Other - Middle Name:
Other - Last Name:OQUENDO SANTIAGO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:711 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-5128
Mailing Address - Country:US
Mailing Address - Phone:352-435-4000
Mailing Address - Fax:
Practice Address - Street 1:711 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5128
Practice Address - Country:US
Practice Address - Phone:352-435-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13694207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0020943Medicare ID - Type UnspecifiedMEDICARE