Healthcare Provider Details

I. General information

NPI: 1902829708
Provider Name (Legal Business Name): ERIC LARUE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 AVENUE K SE STE 5
WINTER HAVEN FL
33880-4146
US

IV. Provider business mailing address

400 AVENUE K SE STE 5
WINTER HAVEN FL
33880-4146
US

V. Phone/Fax

Practice location:
  • Phone: 863-293-3909
  • Fax: 863-293-1909
Mailing address:
  • Phone: 863-293-3909
  • Fax: 863-293-1909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberME0045287
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: