Basic Information
| Provider Information | |||||||||
| NPI: | 1952604696 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLORIDA CANCER SPECIALISTS & RESEARCH INSTITUTE, LLC | ||||||||
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| OtherOrganizationName: | FLORIDA CANCER SPECIALISTS P L | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| 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: | 3280 N MCMULLEN BOOTH RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337612029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7272161141 | ||||||||
| FaxNumber: | 7277966159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2010 | ||||||||
| LastUpdateDate: | 02/04/2019 | ||||||||
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| AuthorizedOfficialLastName: | GORDAN | ||||||||
| AuthorizedOfficialFirstName: | LUCIO | ||||||||
| AuthorizedOfficialMiddleName: | NAVARRO | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 2392748200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0000X | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology | 207RX0202X | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207RH0003X | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 2540169-37 | 05 | FL | MEDICAID |