Provider Demographics
NPI:1972994770
Name:EMMANUEL LAGOUTARIS, DPM, LLC
Entity Type:Organization
Organization Name:EMMANUEL LAGOUTARIS, DPM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EMMANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LAGOUTARIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:904-429-9859
Mailing Address - Street 1:300 KINGSLEY LAKE DR
Mailing Address - Street 2:STE. 402
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-3037
Mailing Address - Country:US
Mailing Address - Phone:904-429-9859
Mailing Address - Fax:
Practice Address - Street 1:300 KINGSLEY LAKE DR
Practice Address - Street 2:STE. 402
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-3037
Practice Address - Country:US
Practice Address - Phone:904-429-9859
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-15
Last Update Date:2016-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3053213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty