Basic Information
| Provider Information | |||||||||
| NPI: | 1619994423 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LASTER | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3601 SW 160TH AVE | ||||||||
| Address2: | SUITE #250 | ||||||||
| City: | MIRAMAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330276308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3058669951 | ||||||||
| FaxNumber: | 8772848933 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 SW 160TH AVE | ||||||||
| Address2: | SUITE #250 | ||||||||
| City: | MIRAMAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330276308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3058669951 | ||||||||
| FaxNumber: | 8772848933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2006 | ||||||||
| LastUpdateDate: | 07/01/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | G8234 | UT | Y | Allopathic & Osteopathic Physicians | Family Medicine | 208600000X | G8234 | TX | N | Allopathic & Osteopathic Physicians | Surgery | 208D00000X | G8234 | TX | N | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 8F0717 | 01 | TX | BCBS | OTHER | P00720965 | 01 | TX | RAILROAD MEDICARE | OTHER | 181470902 | 05 | TX | MEDICAID | 181470901 | 05 | TX | MEDICAID |