Provider Demographics
NPI:1306860382
Name:LASTOMIRSKY, ROBERT R (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:R
Last Name:LASTOMIRSKY
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 1803
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34284-1803
Mailing Address - Country:US
Mailing Address - Phone:941-492-6868
Mailing Address - Fax:
Practice Address - Street 1:740 THE RIALTO
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-3524
Practice Address - Country:US
Practice Address - Phone:941-484-8414
Practice Address - Fax:941-488-7586
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0032829207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME0032829OtherMEDICAL LISCENSE
FLME0032829OtherMEDICAL LISCENSE
FLD56915Medicare UPIN