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General NPI Number Information
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NPI Number | 1831970433
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Entity Type | Organization
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Legal Business Name | LARRY D MASTROGIANAKIS, MD PEDIATRIC AND ADOLESCENT MEDICINE
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Dates
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Enumeration Date | 10/10/2023
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Last Update Date | 10/10/2023
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Provider Practice Location Address
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Address Line | 101 E TOWN PL STE 215
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City | ST AUGUSTINE
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State | FL
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Zip | 32092-2821
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Country | US
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Telephone | 904-429-9989
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Fax |
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Provider Business Mailing Address
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Address Line | 101 E TOWN PL STE 215
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City | ST AUGUSTINE
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State | FL
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Zip | 32092-2821
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Country | US
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Telephone | 904-429-9989
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | LARRY D MASTROGIANAKIS
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Credential | MD
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Telephone | 904-429-9989
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080A0000X
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Taxonomy Name | Pediatric Adolescent Medicine Physician
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License Number |
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License Number State |
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