Provider Demographics
NPI:1831970433
Name:LARRY D MASTROGIANAKIS, MD PEDIATRIC AND ADOLESCENT MEDICINE
Entity type:Organization
Organization Name:LARRY D MASTROGIANAKIS, MD PEDIATRIC AND ADOLESCENT MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:MASTROGIANAKIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-429-9989
Mailing Address - Street 1:101 E TOWN PL STE 215
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-2821
Mailing Address - Country:US
Mailing Address - Phone:904-429-9989
Mailing Address - Fax:
Practice Address - Street 1:101 E TOWN PL STE 215
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-2821
Practice Address - Country:US
Practice Address - Phone:904-429-9989
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-10
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty