Provider Demographics
NPI:1083879225
Name:LAKESIDE FAMILY MEDICINE PLLC
Entity Type:Organization
Organization Name:LAKESIDE FAMILY MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAY
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-256-6465
Mailing Address - Street 1:12060 TEXAS HWY
Mailing Address - Street 2:
Mailing Address - City:MANY
Mailing Address - State:LA
Mailing Address - Zip Code:71449-5605
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12060 TEXAS HWY
Practice Address - Street 2:
Practice Address - City:MANY
Practice Address - State:LA
Practice Address - Zip Code:71449-5605
Practice Address - Country:US
Practice Address - Phone:318-256-6465
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-28
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12198R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4J965Medicare PIN
LAG06287Medicare UPIN