Provider Demographics
NPI:1013359975
Name:LAKE INTERNAL MEDICINE PA
Entity Type:Organization
Organization Name:LAKE INTERNAL MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NAGE
Authorized Official - Middle Name:
Authorized Official - Last Name:KHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-408-9935
Mailing Address - Street 1:293 BENT OAK CT
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-9559
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:293 BENT OAK CT
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-9559
Practice Address - Country:US
Practice Address - Phone:352-408-9935
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-20
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty