Provider Demographics
NPI:1487759809
Name:R. R.LASTOMIRSKY, M.D., P.A.
Entity type:Organization
Organization Name:R. R.LASTOMIRSKY, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:LASTOMIRSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-484-8414
Mailing Address - Street 1:740 THE RIALTO
Mailing Address - Street 2:P. O. BOX 1803
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-3524
Mailing Address - Country:US
Mailing Address - Phone:941-484-8414
Mailing Address - Fax:941-488-7586
Practice Address - Street 1:740 THE RIALTO
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-3524
Practice Address - Country:US
Practice Address - Phone:941-484-8414
Practice Address - Fax:941-488-7586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0032829207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1306860382OtherNPI PHYSICIAN NUMBER
FLME0032829OtherSTATE LISCENSE NUMBER
FL1306860382OtherNPI PHYSICIAN NUMBER
FLME0032829OtherSTATE LISCENSE NUMBER