Provider Demographics
NPI:1265654099
Name:LAKE COUNTY PEDIATRICS LLC
Entity Type:Organization
Organization Name:LAKE COUNTY PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN PEDIATRICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CONSTANCIO
Authorized Official - Middle Name:B
Authorized Official - Last Name:ACOSTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-736-9580
Mailing Address - Street 1:8500 BROADWAY
Mailing Address - Street 2:STE E
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410
Mailing Address - Country:US
Mailing Address - Phone:219-736-9580
Mailing Address - Fax:219-736-9581
Practice Address - Street 1:8500 BROADWAY
Practice Address - Street 2:STE E
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410
Practice Address - Country:US
Practice Address - Phone:219-736-9580
Practice Address - Fax:219-736-9581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01025495208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty