Provider Demographics
NPI:1093747560
Name:LAKE CANCER MEDICAL CENTER PA
Entity Type:Organization
Organization Name:LAKE CANCER MEDICAL CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:MRS
Authorized Official - First Name:LOURDES
Authorized Official - Middle Name:M
Authorized Official - Last Name:MATHEW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-728-2532
Mailing Address - Street 1:732 NORTH THIRD STREET
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748
Mailing Address - Country:US
Mailing Address - Phone:352-728-2532
Mailing Address - Fax:352-728-3004
Practice Address - Street 1:732 NORTH THIRD STREET
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748
Practice Address - Country:US
Practice Address - Phone:352-728-2532
Practice Address - Fax:352-728-3004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81152174400000X
FLME24875207RH0003X
FLME80262207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDE5747OtherRAILROAD MEDICARE
FL94872OtherBCBS
H12555Medicare UPIN
FLK7259Medicare PIN
D54333Medicare UPIN