Provider Demographics
NPI:1932180676
Name:LAGOUTARIS, EMMANUEL D (DPM)
Entity Type:Individual
Prefix:DR
First Name:EMMANUEL
Middle Name:D
Last Name:LAGOUTARIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 COUNTY ROAD 210 W
Mailing Address - Street 2:STE 108, PMB 355
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32259-4060
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6209 BROOKS BARTRAM DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-5601
Practice Address - Country:US
Practice Address - Phone:904-534-9752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2024-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3053213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270009300Medicaid
FL270008501Medicaid
FLU0782ZMedicare PIN
FL270009300Medicaid
FLU0782AMedicare PIN
FLU0782Medicare PIN
FL270008501Medicaid