Provider Demographics
NPI:1336138395
Name:LAMENSDORF, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:LAMENSDORF
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 1:1428 S TAMIAMI TRL
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-2901
Mailing Address - Country:US
Mailing Address - Phone:941-957-4987
Mailing Address - Fax:941-955-7905
Practice Address - Street 1:1428 S TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2901
Practice Address - Country:US
Practice Address - Phone:941-957-4987
Practice Address - Fax:941-955-7905
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0042749174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
58420OtherMEDICARE PTAN
FL069390100Medicaid
58420OtherMEDICARE PTAN