Provider Demographics
NPI:1093185928
Name:LAKESIDE MEDICAL GROUP
Entity Type:Organization
Organization Name:LAKESIDE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER-OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:ANA
Authorized Official - Middle Name:RENTERIA
Authorized Official - Last Name:ZAZUETA
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:888-449-7799
Mailing Address - Street 1:PO BOX 108
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-0108
Mailing Address - Country:US
Mailing Address - Phone:188-844-9779
Mailing Address - Fax:
Practice Address - Street 1:HIDALGO 244
Practice Address - Street 2:
Practice Address - City:CHAPALA
Practice Address - State:MEXICO
Practice Address - Zip Code:45920
Practice Address - Country:MX
Practice Address - Phone:888-449-7799
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-05
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZDGP8902484207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty