Provider Demographics
NPI:1942284179
Name:LASTINGER, LEN B JR (MD)
Entity Type:Individual
Prefix:
First Name:LEN
Middle Name:B
Last Name:LASTINGER
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 1:103 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:GALAX
Mailing Address - State:VA
Mailing Address - Zip Code:24333-2019
Mailing Address - Country:US
Mailing Address - Phone:540-236-3465
Mailing Address - Fax:
Practice Address - Street 1:199 HOSPITAL DR
Practice Address - Street 2:SUITE 5
Practice Address - City:GALAX
Practice Address - State:VA
Practice Address - Zip Code:24333-2454
Practice Address - Country:US
Practice Address - Phone:276-236-6136
Practice Address - Fax:276-236-2536
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101-031905207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005816700Medicaid
VA006092870Medicaid
VA010026466Medicaid
VA005816700Medicaid
VA006092870Medicaid
VA003353C86Medicare PIN
VA017882C18Medicare PIN
VA010026466Medicaid
110007200Medicare PIN