Provider Demographics
NPI:1770602039
Name:CLEARWATER FAMILY PRACTICE, PA
Entity type:Organization
Organization Name:CLEARWATER FAMILY PRACTICE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CESAR
Authorized Official - Middle Name:AGUSTO
Authorized Official - Last Name:LARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-446-3021
Mailing Address - Street 1:1217 EWING AVE
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-3407
Mailing Address - Country:US
Mailing Address - Phone:727-446-3021
Mailing Address - Fax:727-446-7423
Practice Address - Street 1:1217 EWING AVE
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3407
Practice Address - Country:US
Practice Address - Phone:727-446-3021
Practice Address - Fax:727-446-7423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0060883207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK0260Medicare ID - Type Unspecified
FLE19237Medicare UPIN