Provider Demographics
NPI:1164783528
Name:SOUTH LAKE PRIMARY CARE P A
Entity Type:Organization
Organization Name:SOUTH LAKE PRIMARY CARE P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RAMON
Authorized Official - Middle Name:
Authorized Official - Last Name:SUEIRO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-557-4840
Mailing Address - Street 1:1503 SUNRISE PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34714-6200
Mailing Address - Country:US
Mailing Address - Phone:352-243-3800
Mailing Address - Fax:352-243-3804
Practice Address - Street 1:219 W MYERS BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:MASCOTTE
Practice Address - State:FL
Practice Address - Zip Code:34753-9793
Practice Address - Country:US
Practice Address - Phone:352-557-4840
Practice Address - Fax:352-557-4839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-01
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0071348207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG35745Medicare PIN