1194717595 NPI number — DR. EFSTRATIOS DEMETRIOS LAGOUTARIS DPM

Table of content: MS. JOY FAVUZZA NP (NPI 1245258169)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194717595 NPI number — DR. EFSTRATIOS DEMETRIOS LAGOUTARIS DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAGOUTARIS
Provider First Name:
EFSTRATIOS
Provider Middle Name:
DEMETRIOS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194717595
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/20/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5911 TIMUQUANA RD UNIT 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32210-7897
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-251-5053
Provider Business Mailing Address Fax Number:
904-224-2002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1361 13TH AVE S
Provider Second Line Business Practice Location Address:
STE 12
Provider Business Practice Location Address City Name:
JACKSONVILLE BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32250
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-241-2655
Provider Business Practice Location Address Fax Number:
904-249-2425
Provider Enumeration Date:
08/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  PO2989 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 270008501 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: DR7381 . This is a "PALMETTO GBA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 21698L . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 024277500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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