Provider Demographics
NPI:1144400540
Name:SUN 'N LAKE MEDICAL GROUP,PA
Entity Type:Organization
Organization Name:SUN 'N LAKE MEDICAL GROUP,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAISA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMILO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-385-2659
Mailing Address - Street 1:511 W INTERLAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE PLACID
Mailing Address - State:FL
Mailing Address - Zip Code:33852-0703
Mailing Address - Country:US
Mailing Address - Phone:863-699-1220
Mailing Address - Fax:863-699-1811
Practice Address - Street 1:511 W INTERLAKE BLVD
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:FL
Practice Address - Zip Code:33852-0703
Practice Address - Country:US
Practice Address - Phone:863-699-1220
Practice Address - Fax:863-699-1811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME61030208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME61030OtherMEDICAL LICENSE
FL23511OtherBCBS
FL160064OtherHEALTHESE
FL220402OtherHEALTHESE