Provider Demographics
NPI:1366455446
Name:LAKIN, GREGORY
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:
Last Name:LAKIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6550 N FEDERAL HWY
Mailing Address - Street 2:SUITE 320
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-1404
Mailing Address - Country:US
Mailing Address - Phone:954-491-0510
Mailing Address - Fax:954-491-1388
Practice Address - Street 1:6550 N FEDERAL HWY
Practice Address - Street 2:SUITE 320
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-1404
Practice Address - Country:US
Practice Address - Phone:954-491-0510
Practice Address - Fax:954-491-1388
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA116423208200000X
OH35.099884208200000X
FL496688208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0070344Medicaid
OH35.099884OtherLICENSE
CAEZ132ZMedicare PIN
OHH147310Medicare PIN
FLIT116ZMedicare PIN