Provider Demographics
NPI:1063849248
Name:LAKE WALES UROLOGY, LLC
Entity Type:Organization
Organization Name:LAKE WALES UROLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:LOUGHLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-877-2411
Mailing Address - Street 1:1110 DRUID CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-4307
Mailing Address - Country:US
Mailing Address - Phone:863-877-2411
Mailing Address - Fax:863-877-2377
Practice Address - Street 1:1110 DRUID CIR
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4307
Practice Address - Country:US
Practice Address - Phone:863-877-2411
Practice Address - Fax:863-877-2377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-02
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87080208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG76193Medicare UPIN