Provider Demographics
NPI:1043623598
Name:MARK W. LASTARZA, M.D., PA.
Entity Type:Organization
Organization Name:MARK W. LASTARZA, M.D., PA.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:LASTARZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-672-3219
Mailing Address - Street 1:335 CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE 290
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-3181
Mailing Address - Country:US
Mailing Address - Phone:386-672-3219
Mailing Address - Fax:386-672-3160
Practice Address - Street 1:335 CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE 290
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-3181
Practice Address - Country:US
Practice Address - Phone:386-672-3219
Practice Address - Fax:386-672-3160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-03
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME75627207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty