Provider Demographics
NPI:1164408142
Name:LAROYA, PRUDENCIO ESTOLERO (MD)
Entity Type:Individual
Prefix:DR
First Name:PRUDENCIO
Middle Name:ESTOLERO
Last Name:LAROYA
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 1:1801 S 23RD ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-4830
Mailing Address - Country:US
Mailing Address - Phone:772-466-2045
Mailing Address - Fax:772-466-8646
Practice Address - Street 1:1801 S 23RD ST
Practice Address - Street 2:SUITE 3
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-4830
Practice Address - Country:US
Practice Address - Phone:772-466-2045
Practice Address - Fax:772-466-8646
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-21
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME44748208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003471100Medicaid
FL069288300Medicaid
FL069288300Medicaid