Provider Demographics
NPI:1619994423
Name:LASTER, JERRY L (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:L
Last Name:LASTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 742712
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2712
Mailing Address - Country:US
Mailing Address - Phone:877-866-7123
Mailing Address - Fax:
Practice Address - Street 1:17218 PRESTON RD STE 2000
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75252-4018
Practice Address - Country:US
Practice Address - Phone:877-866-7123
Practice Address - Fax:877-284-8933
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8234208600000X, 208D00000X, 207Q00000X
UTG8234207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F0717OtherBCBS
TX181470902Medicaid
TX181470901Medicaid
TXP00720965OtherRAILROAD MEDICARE
TX181470903Medicaid
E69683Medicare UPIN
TX181470902Medicaid
TX8G7952Medicare PIN