Provider Demographics
NPI:1467472068
Name:LAS OLAS MEDICAL GROUP & SPA
Entity Type:Organization
Organization Name:LAS OLAS MEDICAL GROUP & SPA
Other - Org Name:LAS OLAS MEDICAL GROUP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:CARON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-763-1230
Mailing Address - Street 1:2607 NE 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33334-3707
Mailing Address - Country:US
Mailing Address - Phone:954-763-1230
Mailing Address - Fax:954-763-1238
Practice Address - Street 1:2607 NE 10TH AVE
Practice Address - Street 2:
Practice Address - City:WILTON MANORS
Practice Address - State:FL
Practice Address - Zip Code:33334-3707
Practice Address - Country:US
Practice Address - Phone:954-763-1230
Practice Address - Fax:954-763-1238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82806207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL066841900Medicaid
FL066841900Medicaid