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: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 E GARDEN ST STE B
LAKELAND FL
33805-4615
US

IV. Provider business mailing address

PO BOX 878
DAVENPORT FL
33836-0878
US

V. Phone/Fax

Practice location:
  • Phone: 863-588-4775
  • Fax: 863-422-7664
Mailing address:
  • Phone: 689-223-3898
  • Fax: 689-223-3898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: