Provider Demographics
NPI:1518200609
Name:LACA, MORIS (MD)
Entity type:Individual
Prefix:
First Name:MORIS
Middle Name:
Last Name:LACA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5505 FORT PIERCE BLVD # B
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34951-4902
Mailing Address - Country:US
Mailing Address - Phone:813-500-9955
Mailing Address - Fax:
Practice Address - Street 1:2211 OKEECHOBEE RD
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-6552
Practice Address - Country:US
Practice Address - Phone:772-230-5366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-27
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X
FL1330208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program