Provider Demographics
NPI:1376715441
Name:LASCANO, CHARLES A (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:A
Last Name:LASCANO
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 1:5501 N UNIVERSITY DR STE 104
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33067-4645
Mailing Address - Country:US
Mailing Address - Phone:954-757-0670
Mailing Address - Fax:
Practice Address - Street 1:5501 N UNIVERSITY DR STE 104
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33067-4645
Practice Address - Country:US
Practice Address - Phone:954-757-0670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-29
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 103606207QS0010X
FLME103606207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCS823ZMedicare PIN