Provider Demographics
NPI:1760599872
Name:GARCIA, LAUREANO JR (MD)
Entity Type:Individual
Prefix:
First Name:LAUREANO
Middle Name:
Last Name:GARCIA
Suffix:JR
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 1:328 W GODFREY AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120
Mailing Address - Country:US
Mailing Address - Phone:215-549-1100
Mailing Address - Fax:215-549-8074
Practice Address - Street 1:328 W GODFREY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19120
Practice Address - Country:US
Practice Address - Phone:215-549-1100
Practice Address - Fax:215-549-8074
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD066262-L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017453370001Medicaid
PA0157267000OtherBS
PA026312HAFMedicare ID - Type Unspecified
PA0017453370001Medicaid