Provider Demographics
NPI:1417955584
Name:LACK, EDWARD B (MD)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:B
Last Name:LACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:151 SOUTHHALL LN
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7176
Mailing Address - Country:US
Mailing Address - Phone:407-875-2080
Mailing Address - Fax:407-650-3544
Practice Address - Street 1:540 MEDICAL OAKS AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5995
Practice Address - Country:US
Practice Address - Phone:813-651-1991
Practice Address - Fax:813-651-1401
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036-043409207N00000X
FLME114654207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
0021603804OtherBCBS
FLGX723ZMedicare PIN
FLGX723YMedicare PIN