Provider Demographics
NPI:1881723922
Name:PCP OF LAUDERDALE LKS
Entity type:Organization
Organization Name:PCP OF LAUDERDALE LKS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:ANZALONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-318-6590
Mailing Address - Street 1:4900 W OAKLAND PARK BLVD
Mailing Address - Street 2:NORTH BLD SUITE 301
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33313-7500
Mailing Address - Country:US
Mailing Address - Phone:954-484-4154
Mailing Address - Fax:
Practice Address - Street 1:4900 W OAKLAND PARK BLVD
Practice Address - Street 2:NORTH BLD SUITE 301
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33313-7500
Practice Address - Country:US
Practice Address - Phone:954-484-4154
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty