Provider Demographics
NPI:1831165448
Name:LASTARZA, MARK W (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:LASTARZA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:335 CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE 290
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5959
Mailing Address - Country:US
Mailing Address - Phone:386-672-3219
Mailing Address - Fax:386-672-3160
Practice Address - Street 1:335 CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE 290
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5959
Practice Address - Country:US
Practice Address - Phone:386-672-3219
Practice Address - Fax:386-672-3160
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
FLME0075627207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE0974Medicare ID - Type Unspecified
FLG74680Medicare UPIN