Provider Demographics
NPI:1194717595
Name:LAGOUTARIS, EFSTRATIOS DEMETRIOS (DPM)
Entity type:Individual
Prefix:DR
First Name:EFSTRATIOS
Middle Name:DEMETRIOS
Last Name:LAGOUTARIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5911 TIMUQUANA RD UNIT 300
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-7897
Mailing Address - Country:US
Mailing Address - Phone:904-251-5053
Mailing Address - Fax:904-224-2002
Practice Address - Street 1:1361 13TH AVE S
Practice Address - Street 2:STE 12
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250
Practice Address - Country:US
Practice Address - Phone:904-241-2655
Practice Address - Fax:904-249-2425
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2989213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270008501Medicaid
DR7381OtherPALMETTO GBA
21698LOtherBCBS
FL270008501Medicaid
FLK4593AMedicare PIN
FLU91215Medicare UPIN
FL0413700007Medicare NSC
FLK4593Medicare PIN
FL21698LMedicare PIN