Provider Demographics
NPI:1114205457
Name:LAKE NORMAN ENDOCRINOLOGY & DIABETES, PC
Entity Type:Organization
Organization Name:LAKE NORMAN ENDOCRINOLOGY & DIABETES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AUGUSTINE
Authorized Official - Middle Name:U
Authorized Official - Last Name:OBI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-664-2910
Mailing Address - Street 1:143 JOE KNOX AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-9243
Mailing Address - Country:US
Mailing Address - Phone:704-664-2936
Mailing Address - Fax:
Practice Address - Street 1:143 JOE KNOX AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-9243
Practice Address - Country:US
Practice Address - Phone:704-664-2936
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-03
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9400602207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5918299Medicaid
NCA406Medicare PIN