Provider Demographics
NPI:1164615894
Name:YANICK P EUGENE DAUPHIN MDPA
Entity Type:Organization
Organization Name:YANICK P EUGENE DAUPHIN MDPA
Other - Org Name:LADYLAKE MEDICAL CONSULTANTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:YANICK
Authorized Official - Middle Name:PAULE
Authorized Official - Last Name:EUGENE-DAUPHIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-439-4779
Mailing Address - Street 1:4801 S CONGRESS AVE
Mailing Address - Street 2:SUITE 201A
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461-4746
Mailing Address - Country:US
Mailing Address - Phone:561-439-4779
Mailing Address - Fax:561-439-7089
Practice Address - Street 1:4801 S CONGRESS AVE
Practice Address - Street 2:SUITE 201A
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33461-4746
Practice Address - Country:US
Practice Address - Phone:561-439-4779
Practice Address - Fax:561-439-7089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68488207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherEIN