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
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology | 207ZC0006X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology | 207ZH0000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Hematology | 207ZP0102X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 2085R0001X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0202X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0203X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Therapeutic Radiology | 291U00000X |   |   | N |   | Laboratories | Clinical Medical Laboratory |   | 207RX0202X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
ID | Type | State | Issuer | Description | 2540169-38 | 05 | FL |   | MEDICAID | 2540169-39 | 05 | FL |   | MEDICAID | 2540169-41 | 05 | FL |   | MEDICAID | 254016900 | 05 | FL |   | MEDICAID | 254016902 | 05 | FL |   | MEDICAID | 254016915 | 05 | FL |   | MEDICAID | 254016917 | 05 | FL |   | MEDICAID | 254016919 | 05 | FL |   | MEDICAID | 2540169-35 | 05 | FL |   | MEDICAID | 254016904 | 05 | FL |   | MEDICAID | 254016918 | 05 | FL |   | MEDICAID | 254016922 | 05 | FL |   | MEDICAID | 254016931 | 05 | FL |   | MEDICAID | 254016934 | 05 | FL |   | MEDICAID | 254016909 | 05 | FL |   | MEDICAID | 254016910 | 05 | FL |   | MEDICAID | 254016912 | 05 | FL |   | MEDICAID | 254016916 | 05 | FL |   | MEDICAID | 2540169-42 | 05 | FL |   | MEDICAID | 2540169-43 | 05 | FL |   | MEDICAID | 254016930 | 05 | FL |   | MEDICAID | 254016932 | 05 | FL |   | MEDICAID | 2540169-40 | 05 | FL |   | MEDICAID | 254016901 | 05 | FL |   | MEDICAID | 254016908 | 05 | FL |   | MEDICAID | 254016924 | 05 | FL |   | MEDICAID | 2540169-37 | 05 | FL |   | MEDICAID | 254016906 | 05 | FL |   | MEDICAID | 254016920 | 05 | FL |   | MEDICAID | 254016928 | 05 | FL |   | MEDICAID | 254016933 | 05 | FL |   | MEDICAID | 254016911 | 05 | FL |   | MEDICAID | 254016913 | 05 | FL |   | MEDICAID | 254016903 | 05 | FL |   | MEDICAID | 254016925 | 05 | FL |   | MEDICAID | 254016927 | 05 | FL |   | MEDICAID | 254016929 | 05 | FL |   | MEDICAID |