Provider Demographics
NPI:1295221943
Name:LASTRA CABEZA, ALEXANDER (MD)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:LASTRA CABEZA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9888
Mailing Address - Fax:239-343-4262
Practice Address - Street 1:650 DEL PRADO BLVD S STE 107
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-5629
Practice Address - Country:US
Practice Address - Phone:239-343-9888
Practice Address - Fax:239-343-4265
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-05
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME147340208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110519200Medicaid