MEDICARE: LAS OLAS MEDICAL GROUP & SPA

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	207Q00000X	Family Medicine Physician	ME82806	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

General Provider Information

NPI Number	:	1467472068
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAS OLAS MEDICAL GROUP & SPA

Provider Business Mailing Address
First Line	:	2607 NE 10TH AVE
Second Line	:
City	:	WILTON MANORS
State	:	FL
Zip	:	33334-3707
Country	:	US
Telephone Number	:	954-763-1230
Fax Number	:	954-763-1238

Provider Business Practice Location Address
First Line	:	2607 NE 10TH AVE
Second Line	:
City	:	WILTON MANORS
State	:	FL
Zip	:	33334-3707
Country	:	US
Telephone Number	:	954-763-1230
Fax Number	:	954-763-1238

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. JEFFREY S CARON
Credential	:	M.D.
Telephone Number	:	954-763-1230

Provider Enumeration Date	:	07/19/2006
Last Update Date	:	08/26/2008

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