Provider Demographics
NPI:1275933780
Name:LAKEWOOD DERMATOLOGY
Entity Type:Organization
Organization Name:LAKEWOOD DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:NEIDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-458-0322
Mailing Address - Street 1:14701 DETROIT AVE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-4115
Mailing Address - Country:US
Mailing Address - Phone:216-458-0322
Mailing Address - Fax:216-458-0325
Practice Address - Street 1:14701 DETROIT AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-4115
Practice Address - Country:US
Practice Address - Phone:216-458-0322
Practice Address - Fax:216-458-0325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-03
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35081781207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0065021Medicaid
OH0065021Medicaid