Provider Demographics
NPI:1063486819
Name:LACANO, CRISOSTOMO V (MD)
Entity Type:Individual
Prefix:DR
First Name:CRISOSTOMO
Middle Name:V
Last Name:LACANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 919346
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-9346
Mailing Address - Country:US
Mailing Address - Phone:727-896-3134
Mailing Address - Fax:770-666-9331
Practice Address - Street 1:110 LONGWOOD AVENUE
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955
Practice Address - Country:US
Practice Address - Phone:321-636-2211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL294092085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL05401OtherBCBS
FL039490400Medicaid
FL039490400Medicaid