Healthcare Provider Details

I. General information

NPI: 1407815525
Provider Name (Legal Business Name): LUIS FERNANDO LAOS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2006
Last Update Date: 01/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1893 KINGSLEY AVE SUITE C
ORANGE PARK FL
32073-4491
US

IV. Provider business mailing address

1893 KINGSLEY AVE SUITE C
ORANGE PARK FL
32073-4491
US

V. Phone/Fax

Practice location:
  • Phone: 904-276-2044
  • Fax: 904-276-2106
Mailing address:
  • Phone: 904-276-2044
  • Fax: 904-276-2106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME70461
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberME70461
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberME70461
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: