Healthcare Provider Details

I. General information

NPI: 1790744878
Provider Name (Legal Business Name): SERGIO W. LARACH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2006
Last Update Date: 02/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N DEAN RD SUITE 101
ORLANDO FL
32825-3710
US

IV. Provider business mailing address

100 N DEAN RD SUITE 101
ORLANDO FL
32825-3710
US

V. Phone/Fax

Practice location:
  • Phone: 407-384-7388
  • Fax: 407-384-7391
Mailing address:
  • Phone: 407-384-7388
  • Fax: 407-384-7391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberME25149
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: