Provider Demographics
NPI:1013214261
Name:G BROCK MAGRUDER JR MD PA
Entity Type:Organization
Organization Name:G BROCK MAGRUDER JR MD PA
Other - Org Name:LASERVUE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:B
Authorized Official - Last Name:MAGRUDER
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:407-843-5665
Mailing Address - Street 1:120 E PAR ST
Mailing Address - Street 2:SUITE 2000
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-3943
Mailing Address - Country:US
Mailing Address - Phone:407-843-5665
Mailing Address - Fax:407-872-7939
Practice Address - Street 1:120 E PAR ST
Practice Address - Street 2:SUITE 2000
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-3943
Practice Address - Country:US
Practice Address - Phone:407-843-5665
Practice Address - Fax:407-872-7939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-24
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME56293207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty