Provider Demographics
NPI:1295747806
Name:PRUDENCIO E. LAROYA, M.D. PA
Entity type:Organization
Organization Name:PRUDENCIO E. LAROYA, M.D. PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PRUDENCIO
Authorized Official - Middle Name:ESTOLERO
Authorized Official - Last Name:LAROYA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-466-2045
Mailing Address - Street 1:1801 S 23RD ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-4830
Mailing Address - Country:US
Mailing Address - Phone:772-466-2045
Mailing Address - Fax:772-466-8646
Practice Address - Street 1:1801 S 23RD ST
Practice Address - Street 2:SUITE 3
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-4830
Practice Address - Country:US
Practice Address - Phone:772-466-2045
Practice Address - Fax:772-466-8646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL069288300Medicaid
FL000366600Medicaid
FL003471100Medicaid