MEDICARE: DR. PRUDENCIO ESTOLERO LAROYA 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	208000000X	Pediatrics Physician	ME44748	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164408142
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PRUDENCIO ESTOLERO LAROYA M.D.

Provider Business Mailing Address
First Line	:	1801 S 23RD ST
Second Line	:	SUITE 3
City	:	FORT PIERCE
State	:	FL
Zip	:	34950-4830
Country	:	US
Telephone Number	:	772-466-2045
Fax Number	:	772-466-8646

Provider Business Practice Location Address
First Line	:	1801 S 23RD ST
Second Line	:	SUITE 3
City	:	FORT PIERCE
State	:	FL
Zip	:	34950-4830
Country	:	US
Telephone Number	:	772-466-2045
Fax Number	:	772-466-8646

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

Provider Enumeration Date	:	12/21/2005
Last Update Date	:	01/14/2019

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