Provider Demographics
NPI:1104870831
Name:LYSAKER, EARL C (MD)
Entity type:Individual
Prefix:
First Name:EARL
Middle Name:C
Last Name:LYSAKER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:5700 LAKE WORTH RD
Mailing Address - Street 2:#204
Mailing Address - City:GREENACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33463-4727
Mailing Address - Country:US
Mailing Address - Phone:561-968-7968
Mailing Address - Fax:561-964-4603
Practice Address - Street 1:1397 MEDICAL PARK BLVD.
Practice Address - Street 2:# 340
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414
Practice Address - Country:US
Practice Address - Phone:561-795-2008
Practice Address - Fax:561-795-4214
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2007-10-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLMEA5381207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL61412Medicare PIN
D57229Medicare UPIN