Provider Demographics
NPI:1700878451
Name:LOURIE, JOHN KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:KENNETH
Last Name:LOURIE
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 1:4900 MANATEE AVE. W, SUITE 201
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209
Mailing Address - Country:US
Mailing Address - Phone:941-746-5200
Mailing Address - Fax:941-746-5266
Practice Address - Street 1:4900 MANATEE AVE. W, SUITE 201
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209
Practice Address - Country:US
Practice Address - Phone:941-746-5200
Practice Address - Fax:941-746-5266
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0068394207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL378088100Medicaid
FL205060385OtherTAX ID
FL27143OtherBCBS OF FL
FL205060385OtherTAX ID
FL27143OtherBCBS OF FL