Provider Demographics
NPI:1023090800
Name:MASTROGIANAKIS, LARRY (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:MASTROGIANAKIS
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 1:12428 SAN JOSE BLVD
Mailing Address - Street 2:STE 3
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-8616
Mailing Address - Country:US
Mailing Address - Phone:904-260-9495
Mailing Address - Fax:904-260-3009
Practice Address - Street 1:12428 SAN JOSE BLVD
Practice Address - Street 2:STE 3
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8616
Practice Address - Country:US
Practice Address - Phone:904-260-9495
Practice Address - Fax:904-260-3009
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME44927174400000X
FL44927208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist