Provider Demographics
NPI:1063495679
Name:STILLMAN, LAURENCE P (DO)
Entity Type:Individual
Prefix:
First Name:LAURENCE
Middle Name:P
Last Name:STILLMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1090 PAPAYA ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33019-4842
Mailing Address - Country:US
Mailing Address - Phone:305-904-0037
Mailing Address - Fax:954-927-9493
Practice Address - Street 1:1090 PAPAYA ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33019-4842
Practice Address - Country:US
Practice Address - Phone:305-904-0037
Practice Address - Fax:954-927-9493
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS4079174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD27361Medicare UPIN