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General NPI Number Information
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NPI Number | 1033308515
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Entity Type | Organization
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Legal Business Name | LAKELAND UROLOGY PA
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Dates
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Enumeration Date | 10/19/2007
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Last Update Date | 12/12/2007
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Provider Practice Location Address
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Address Line | 4435 FLORIDA NATIONAL DR
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City | LAKELAND
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State | FL
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Zip | 33813-1516
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Country | US
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Telephone | 863-644-0471
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Fax | 863-644-9400
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Provider Business Mailing Address
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Address Line | PO BOX 250
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City | HIGHLAND CITY
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State | FL
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Zip | 33846-0250
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Country | US
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Telephone | 863-644-0471
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Fax | 863-644-9400
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Authorized Official
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Title or Position | OWNER
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Name | EDUARDO C MORENO
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Credential | M.D.
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Telephone | 863-644-0471
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | ME0029790
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License Number State | FL
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