Healthcare Provider Details

I. General information

NPI: 1194717595
Provider Name (Legal Business Name): EFSTRATIOS DEMETRIOS LAGOUTARIS DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 02/20/2024
Certification Date: 08/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1361 13TH AVE S STE 12
JACKSONVILLE BEACH FL
32250
US

IV. Provider business mailing address

5911 TIMUQUANA RD UNIT 300
JACKSONVILLE FL
32210-7897
US

V. Phone/Fax

Practice location:
  • Phone: 904-241-2655
  • Fax: 904-249-2425
Mailing address:
  • Phone: 904-251-5053
  • Fax: 904-224-2002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO2989
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: