Provider Demographics
NPI:1053375584
Name:PREMOLI, JUAN (MD)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:PREMOLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:MANAGED CARE DEPT
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:21150 BISCAYNE BLVD
Practice Address - Street 2:404
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-1226
Practice Address - Country:US
Practice Address - Phone:305-466-9111
Practice Address - Fax:305-466-9127
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME87618174400000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL275037600Medicaid
FL81710OtherBCBS FL
FLP01720865OtherSIMPLY HEALTHCARE
FL240750OtherWELLCARE
FLP0003165OtherFLORIDA HEALTHCARE PLUS
FL7845484OtherAETNA PROVIDER #
FLP00721043OtherRR MEDICARE PTAN
FLQMP000003854191OtherMOLINA
FL81710OtherBCBS FL
FL81710WMedicare PIN
FLH97726Medicare UPIN
FL240750OtherWELLCARE