Provider Demographics
NPI:1467464917
Name:PHYSICIANS STAT LAB INC.
Entity Type:Organization
Organization Name:PHYSICIANS STAT LAB INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FRANCISCO
Authorized Official - Middle Name:
Authorized Official - Last Name:URTEAGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-496-9038
Mailing Address - Street 1:4290 S HWY 27 STE 204
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-8066
Mailing Address - Country:US
Mailing Address - Phone:833-782-8522
Mailing Address - Fax:
Practice Address - Street 1:4290 S HWY 27 STE 204
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-8066
Practice Address - Country:US
Practice Address - Phone:833-782-8522
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLL800011974291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL119047100Medicaid
FLL9069OtherBCBS