Provider Demographics
NPI:1184645368
Name:ONTARIO LAKESIDE MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:ONTARIO LAKESIDE MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:O
Authorized Official - Last Name:DATOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-342-8552
Mailing Address - Street 1:90 W UTICA ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-3048
Mailing Address - Country:US
Mailing Address - Phone:315-342-8552
Mailing Address - Fax:315-342-8572
Practice Address - Street 1:90 W UTICA ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126
Practice Address - Country:US
Practice Address - Phone:315-342-8552
Practice Address - Fax:315-342-8572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1828341207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ100024170Medicare PIN