Provider Demographics
NPI:1952467490
Name:LASTRA, JORGE J (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:J
Last Name:LASTRA
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:MANATI MEDICAL CENTER
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MANATI
Mailing Address - State:PR
Mailing Address - Zip Code:00674
Mailing Address - Country:US
Mailing Address - Phone:787-621-3737
Mailing Address - Fax:787-621-3251
Practice Address - Street 1:MANATI MEDICAL CENTER
Practice Address - Street 2:SUITE 201
Practice Address - City:MANATI
Practice Address - State:PR
Practice Address - Zip Code:00674
Practice Address - Country:US
Practice Address - Phone:787-621-3737
Practice Address - Fax:787-621-3251
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13229207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR20195LAMedicare ID - Type UnspecifiedMEDICARE NUMBER
PRH05522Medicare UPIN