MEDICARE: LAKRYSTAL J WARREN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	ME108432	FL

General Provider Information

NPI Number	:	1063617942
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAKRYSTAL J WARREN M.D.

Provider Business Mailing Address
First Line	:	2111 GLENWOOD DR
Second Line	:	SUITE 208
City	:	WINTER PARK
State	:	FL
Zip	:	32792-3328
Country	:	US
Telephone Number	:	407-478-6249
Fax Number	:	407-478-6250

Provider Business Practice Location Address
First Line	:	2111 GLENWOOD DR
Second Line	:	SUITE 208
City	:	WINTER PARK
State	:	FL
Zip	:	32792-3328
Country	:	US
Telephone Number	:	407-478-6249
Fax Number	:	407-478-6250

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/19/2007
Last Update Date	:	09/07/2011

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