Provider Demographics
NPI:1831153055
Name:LACSON, J. AGUSTIN (MD)
Entity type:Individual
Prefix:
First Name:J. AGUSTIN
Middle Name:
Last Name:LACSON
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:PO BOX 7514
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33872-0109
Mailing Address - Country:US
Mailing Address - Phone:863-385-6700
Mailing Address - Fax:
Practice Address - Street 1:3300 US 27 S
Practice Address - Street 2:
Practice Address - City:AVON PARK
Practice Address - State:FL
Practice Address - Zip Code:33825-9701
Practice Address - Country:US
Practice Address - Phone:863-385-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0072358207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL44661OtherBLUE CROSS BLUE SHIELD
FL024129700Medicaid
FL110241195OtherRAILROAD MEDICARE
FL110241195OtherRAILROAD MEDICARE
FL44661OtherBLUE CROSS BLUE SHIELD