Provider Demographics
NPI:1114105442
Name:LAKE SURGICAL CLINIC PA
Entity Type:Organization
Organization Name:LAKE SURGICAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:W
Authorized Official - Last Name:BURNSED
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-787-8230
Mailing Address - Street 1:1111 W DIXIE AVE
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-6386
Mailing Address - Country:US
Mailing Address - Phone:352-787-8230
Mailing Address - Fax:352-787-6964
Practice Address - Street 1:1111 W DIXIE AVE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-6386
Practice Address - Country:US
Practice Address - Phone:352-787-8230
Practice Address - Fax:352-787-6964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-08
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME16817174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK0016Medicare PIN