Provider Demographics
NPI:1184846776
Name:LAKESIDE MEDICAL ASSOCIATES, P. A.
Entity Type:Organization
Organization Name:LAKESIDE MEDICAL ASSOCIATES, P. A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:VOLLENWEIDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-625-7000
Mailing Address - Street 1:6053 MAIN ST
Mailing Address - Street 2:SUITE 130
Mailing Address - City:THE COLONY
Mailing Address - State:TX
Mailing Address - Zip Code:75056-4706
Mailing Address - Country:US
Mailing Address - Phone:972-625-7000
Mailing Address - Fax:972-625-8787
Practice Address - Street 1:6053 MAIN ST
Practice Address - Street 2:SUITE 130
Practice Address - City:THE COLONY
Practice Address - State:TX
Practice Address - Zip Code:75056-4706
Practice Address - Country:US
Practice Address - Phone:972-625-7000
Practice Address - Fax:972-625-8787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF2507207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00J99XMedicare PIN