Healthcare Provider Details

I. General information

NPI: 1245220698
Provider Name (Legal Business Name): LAERTES A MANUELIDIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8381 RIVERWALK PARK BLVD SUITE 1
FORT MYERS FL
33919-8760
US

IV. Provider business mailing address

8381 RIVERWALK PARK BLVD SUITE 101
FORT MYERS FL
33919-8760
US

V. Phone/Fax

Practice location:
  • Phone: 239-936-5425
  • Fax: 239-936-5176
Mailing address:
  • Phone: 239-936-5425
  • Fax: 239-936-5176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License NumberME87314
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberME87314
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: