Basic Information
Provider Information
NPI: 1760590962
EntityType: 2
ReplacementNPI:  
OrganizationName: FLORIDA CANCER SPECIALISTS & RESEARCH INSTITUTE, LLC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: FLORIDA CANCER SPECIALISTS P L
OtherOrganizationType: 4
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4371 VERONICA S SHOEMAKER BLVD
Address2: ATTN: CREDENTIAL DEPT
City: FORT MYERS
State: FL
PostalCode: 339162216
CountryCode: US
TelephoneNumber: 2392748200
FaxNumber: 2392783350
Practice Location
Address1: 1708 CAPE CORAL PKWY W
Address2: #10
City: CAPE CORAL
State: FL
PostalCode: 339146985
CountryCode: US
TelephoneNumber: 2395414633
FaxNumber: 2395411825
Other Information
ProviderEnumerationDate: 08/28/2006
LastUpdateDate: 04/27/2022
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: GORDAN
AuthorizedOfficialFirstName: LUCIO
AuthorizedOfficialMiddleName: N.
AuthorizedOfficialTitleorPosition: PRESIDENT/MANAGING PARTNER
AuthorizedOfficialTelephone: 3523323900
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: M.D.
NPICertificationDate: 04/27/2022

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207RH0000X  N193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansInternal MedicineHematology
207ZC0006X  N193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansPathologyClinical Pathology
207ZH0000X  N193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansPathologyHematology
207ZP0102X  N193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
2085R0001X  N193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
2085R0202X  N193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
2085R0203X  N193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
291U00000X  N LaboratoriesClinical Medical Laboratory 
207RX0202X  Y193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology

ID Information
IDTypeStateIssuerDescription
2540169-3805FL MEDICAID
2540169-3905FL MEDICAID
2540169-4105FL MEDICAID
25401690005FL MEDICAID
25401690205FL MEDICAID
25401691505FL MEDICAID
25401691705FL MEDICAID
25401691905FL MEDICAID
2540169-3505FL MEDICAID
25401690405FL MEDICAID
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25401692205FL MEDICAID
25401693105FL MEDICAID
25401693405FL MEDICAID
25401690905FL MEDICAID
25401691005FL MEDICAID
25401691205FL MEDICAID
25401691605FL MEDICAID
2540169-4205FL MEDICAID
2540169-4305FL MEDICAID
25401693005FL MEDICAID
25401693205FL MEDICAID
2540169-4005FL MEDICAID
25401690105FL MEDICAID
25401690805FL MEDICAID
25401692405FL MEDICAID
2540169-3705FL MEDICAID
25401690605FL MEDICAID
25401692005FL MEDICAID
25401692805FL MEDICAID
25401693305FL MEDICAID
25401691105FL MEDICAID
25401691305FL MEDICAID
25401690305FL MEDICAID
25401692505FL MEDICAID
25401692705FL MEDICAID
25401692905FL MEDICAID


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