Provider Demographics
NPI:1821088782
Name:EJERCITO, LORENA L
Entity Type:Individual
Prefix:DR
First Name:LORENA
Middle Name:L
Last Name:EJERCITO
Suffix:
Gender:F
Credentials:
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 863407
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-3407
Mailing Address - Country:US
Mailing Address - Phone:941-917-2600
Mailing Address - Fax:941-917-7884
Practice Address - Street 1:1921 WALDEMERE ST
Practice Address - Street 2:SUITE 605
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2943
Practice Address - Country:US
Practice Address - Phone:941-917-8100
Practice Address - Fax:941-917-6334
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME76113207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL258270800Medicaid
FL46304OtherBCBS
FL258270800Medicaid
FL46304ZMedicare PIN