=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023422425
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JORGE L. LACEN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2014
-----------------------------------------------------
Last Update Date | 05/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 33044 US HWY 27 N
-----------------------------------------------------
City | HAINES CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33844-7621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-422-4977
-----------------------------------------------------
Fax | 863-422-7786
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 425 W COLONIAL DR STE 303
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32804-6863
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-332-6947
-----------------------------------------------------
Fax | 407-286-4515
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 18764
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | ACN1035
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------