Provider Demographics
NPI:1003096991
Name:LAKESHORE ENT
Entity Type:Organization
Organization Name:LAKESHORE ENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:KRZEMINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DO, FAOCO
Authorized Official - Phone:817-573-6673
Mailing Address - Street 1:1305 PALUXY RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76048-5641
Mailing Address - Country:US
Mailing Address - Phone:817-573-6673
Mailing Address - Fax:817-573-9783
Practice Address - Street 1:1305 PALUXY RD
Practice Address - Street 2:SUITE A
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-5641
Practice Address - Country:US
Practice Address - Phone:817-573-6673
Practice Address - Fax:817-573-9783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-07
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8272207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00564XMedicare PIN