Provider Demographics
NPI:1285645911
Name:LAKE AREA PEDIATRICS
Entity Type:Organization
Organization Name:LAKE AREA PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:S
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-582-5620
Mailing Address - Street 1:18057 HWY 105 WEST
Mailing Address - Street 2:STE. 220
Mailing Address - City:MONTGOMERY
Mailing Address - State:TX
Mailing Address - Zip Code:77356
Mailing Address - Country:US
Mailing Address - Phone:936-582-5620
Mailing Address - Fax:936-582-5621
Practice Address - Street 1:18057 HWY 105 WEST
Practice Address - Street 2:STE. 220
Practice Address - City:MONTGOMERY
Practice Address - State:TX
Practice Address - Zip Code:77356
Practice Address - Country:US
Practice Address - Phone:936-582-5620
Practice Address - Fax:936-582-5621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL3800208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX158814702Medicaid
TX1740276856OtherINDIVIDUAL NPI
TX158814702Medicaid