Healthcare Provider Details

I. General information

NPI: 1861405508
Provider Name (Legal Business Name): THE COLON AND RECTAL CLINIC OF FT LAUDERDALE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 NW 82ND AVE SUITE 302
PLANTATION FL
33324
US

IV. Provider business mailing address

201 NW 82ND AVE SUITE 302
PLANTATION FL
33324
US

V. Phone/Fax

Practice location:
  • Phone: 954-236-5444
  • Fax: 954-236-5422
Mailing address:
  • Phone: 954-236-5444
  • Fax: 954-236-5422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: CHARLES PETER LAGO SR.
Title or Position: PRESIDENT FOR THE PRACTICE
Credential: MD
Phone: 954-236-5444