Provider Demographics
NPI:1063449346
Name:LAKE PODIATRY, PC
Entity Type:Organization
Organization Name:LAKE PODIATRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:RAZIUDDIN
Authorized Official - Middle Name:
Authorized Official - Last Name:AHMED
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:818-518-6768
Mailing Address - Street 1:10570 BLUE STAR M HWY
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-8923
Mailing Address - Country:US
Mailing Address - Phone:269-978-3385
Mailing Address - Fax:269-978-2711
Practice Address - Street 1:10570 BLUE STAR M HWY
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-8923
Practice Address - Country:US
Practice Address - Phone:269-978-3385
Practice Address - Fax:269-978-2711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002029213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4952336Medicaid
MIDF2298OtherRAILROAD MEDICARE
MI6182430001Medicare NSC
MI0P35320Medicare ID - Type Unspecified