Provider Demographics
NPI:1245220698
Name:MANUELIDIS, LAERTES A (MD)
Entity Type:Individual
Prefix:
First Name:LAERTES
Middle Name:A
Last Name:MANUELIDIS
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 1:8381 RIVERWALK PARK BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-8760
Mailing Address - Country:US
Mailing Address - Phone:239-936-5425
Mailing Address - Fax:239-936-5176
Practice Address - Street 1:8381 RIVERWALK PARK BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-8760
Practice Address - Country:US
Practice Address - Phone:239-936-5425
Practice Address - Fax:239-936-5176
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87314207ZD0900X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
Not Answered207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7082420OtherAETNA
FL78611OtherBC BS OF FLA
FLP00038301OtherRR MEDICARE
H87718Medicare UPIN
FL7082420OtherAETNA