Healthcare Provider Details

I. General information

NPI: 1831970433
Provider Name (Legal Business Name): LARRY D MASTROGIANAKIS, MD PEDIATRIC AND ADOLESCENT MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2023
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E TOWN PL STE 215
ST AUGUSTINE FL
32092-2821
US

IV. Provider business mailing address

101 E TOWN PL STE 215
ST AUGUSTINE FL
32092-2821
US

V. Phone/Fax

Practice location:
  • Phone: 904-429-9989
  • Fax:
Mailing address:
  • Phone: 904-429-9989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LARRY D MASTROGIANAKIS
Title or Position: OWNER
Credential: MD
Phone: 904-429-9989