Provider Demographics
NPI:1487836698
Name:CARL W LENTZ III, M.D., P.A.
Entity Type:Organization
Organization Name:CARL W LENTZ III, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:W
Authorized Official - Last Name:LENTZ
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:386-252-8051
Mailing Address - Street 1:1265 W GRANADA BLVD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174
Mailing Address - Country:US
Mailing Address - Phone:386-252-8051
Mailing Address - Fax:386-252-1173
Practice Address - Street 1:1265 W GRANADA BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174
Practice Address - Country:US
Practice Address - Phone:386-252-8051
Practice Address - Fax:386-252-1173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0023708208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD82518Medicare UPIN
FLK0390Medicare PIN