Provider Demographics
NPI:1164485843
Name:GILDERMAN, LARRY I (DO)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:I
Last Name:GILDERMAN
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 1:1150 N UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-5031
Mailing Address - Country:US
Mailing Address - Phone:954-432-7860
Mailing Address - Fax:954-432-2109
Practice Address - Street 1:1150 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-5031
Practice Address - Country:US
Practice Address - Phone:954-432-7860
Practice Address - Fax:954-432-2109
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0003370207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL052423900Medicaid
FLD77254Medicare UPIN
FL81876YMedicare ID - Type Unspecified