Provider Demographics
NPI:1598831224
Name:LARGEN & CLONTZ SURGICAL ASSOCIATES PA
Entity Type:Organization
Organization Name:LARGEN & CLONTZ SURGICAL ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COOR
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:E
Authorized Official - Last Name:NUTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-322-7841
Mailing Address - Street 1:819 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771
Mailing Address - Country:US
Mailing Address - Phone:407-322-7841
Mailing Address - Fax:407-322-1778
Practice Address - Street 1:819 E 1ST ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771
Practice Address - Country:US
Practice Address - Phone:407-322-7841
Practice Address - Fax:407-322-1778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL045563600Medicaid
D57014Medicare UPIN
59055Medicare ID - Type Unspecified