Edward B Lack, MD

Primary specialty

Dermatology PhysicianTaxonomy code 207N00000X

License

036-043409 Issued in IL

Practice address

540 Medical Oaks Ave
Suite 102
Brandon, FL 33511-5995

Phone

(813) 651-1991

Fax

(813) 651-1401

NPI assigned

Jul 12, 2005

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1121126400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1479168000000",
    "number": "1417955584",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "151 SOUTHHALL LN",
            "address_2": "SUITE 300",
            "city": "MAITLAND",
            "state": "FL",
            "postal_code": "327517176",
            "telephone_number": "407-875-2080",
            "fax_number": "407-650-3544"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "540 MEDICAL OAKS AVE",
            "address_2": "SUITE 102",
            "city": "BRANDON",
            "state": "FL",
            "postal_code": "335115995",
            "telephone_number": "813-651-1991",
            "fax_number": "813-651-1401"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "LACK",
        "first_name": "EDWARD",
        "middle_name": "B",
        "name_prefix": "Mr.",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-07-12",
        "last_updated": "2016-11-15",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": "IL",
            "license": "036-043409",
            "primary": true
        },
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": "FL",
            "license": "ME114654",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "0021603804",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Imilsis La Rosa Silveira, RBT-25-499538
• Joel Mark Laatsch, LMHC, NCC
• Yazmin Laboy
• Eraimy Labrada Ortiz
• Brittany Labrecque
• Nichole Lackmann
• Keneysha Ladner
• Kaia Lafler
• Carmen Laguna, RDH
• Monica Lake, PSYD, NCSP

• Dermatology Physician in Brandon, FL
• Providers in Brandon, FL by specialty
• Dermatology Physician in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 15, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.