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General NPI Number Information
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NPI Number | 1619178654
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Entity Type | Organization
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Legal Business Name | LAWRENCE R. BLACK, D.O., P.A.
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Dates
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Enumeration Date | 05/29/2007
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Last Update Date | 04/03/2013
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Provider Practice Location Address
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Address Line | 13691 METRO PKWY SUITE 350
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City | FORT MYERS
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State | FL
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Zip | 33912-4327
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Country | US
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Telephone | 239-768-5313
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Fax | 239-768-9559
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Provider Business Mailing Address
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Address Line | 13691 METRO PKWY SUITE 350
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City | FORT MYERS
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State | FL
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Zip | 33912-4327
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | KAREN DESANTIS
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Credential |
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Telephone | 239-768-5313
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | OS5736
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License Number State | FL
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