Healthcare Provider Details

I. General information

NPI: 1255081147
Provider Name (Legal Business Name): TIMOTHY LASSETER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2022
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 FERRIS ST
GREEN COVE SPRINGS FL
32043-4025
US

IV. Provider business mailing address

2675 WINKLER AVE STE 200
FORT MYERS FL
33901-9328
US

V. Phone/Fax

Practice location:
  • Phone: 904-284-4510
  • Fax: 904-284-3293
Mailing address:
  • Phone: 877-856-3774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberOS21902
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS21902
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: