Healthcare Provider Details

I. General information

NPI: 1023422425
Provider Name (Legal Business Name): JORGE L. LACEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2014
Last Update Date: 05/16/2024
Certification Date: 05/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33044 US HWY 27 N
HAINES CITY FL
33844-7621
US

IV. Provider business mailing address

425 W COLONIAL DR STE 303
ORLANDO FL
32804-6863
US

V. Phone/Fax

Practice location:
  • Phone: 863-422-4977
  • Fax: 863-422-7786
Mailing address:
  • Phone: 321-332-6947
  • Fax: 407-286-4515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number18764
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberACN1035
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: