Healthcare Provider Details

I. General information

NPI: 1912113523
Provider Name (Legal Business Name): COLON AND RECTAL CLINIC OF FORT LAUDERDALE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 06/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 N PINE ISLAND RD SUITE 300
PLANTATION FL
33324-1849
US

IV. Provider business mailing address

PO BOX 15466
PLANTATION FL
33318-5466
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: DR. CHARLES PETER LAGO SR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 954-236-5444