MEDICARE: PCP OF LAUDERDALE LKS

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

General Provider Information

NPI Number	:	1881723922
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PCP OF LAUDERDALE LKS

Provider Business Mailing Address
First Line	:	4900 W OAKLAND PARK BLVD
Second Line	:	NORTH BLD SUITE 301
City	:	LAUDERDALE LAKES
State	:	FL
Zip	:	33313-7500
Country	:	US
Telephone Number	:	954-484-4154
Fax Number	:

Provider Business Practice Location Address
First Line	:	4900 W OAKLAND PARK BLVD
Second Line	:	NORTH BLD SUITE 301
City	:	LAUDERDALE LAKES
State	:	FL
Zip	:	33313-7500
Country	:	US
Telephone Number	:	954-484-4154
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	PETER ANZALONE
Credential	:
Telephone Number	:	954-318-6590

Provider Enumeration Date	:	03/05/2007
Last Update Date	:	08/22/2020

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Directions to “PCP OF LAUDERDALE LKS ” Practice Location

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