Provider Demographics
NPI:1346255056
Name:SOUTH LAKE ANESTHESIA SERVICES, P.A.
Entity Type:Organization
Organization Name:SOUTH LAKE ANESTHESIA SERVICES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:S
Authorized Official - Last Name:GHIVIZZANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-243-9114
Mailing Address - Street 1:PO BOX 100024
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30348-0024
Mailing Address - Country:US
Mailing Address - Phone:352-243-9114
Mailing Address - Fax:352-243-7822
Practice Address - Street 1:1900 DON WICKHAM DR
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-1979
Practice Address - Country:US
Practice Address - Phone:352-243-9114
Practice Address - Fax:352-243-7822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207L00000X, 367500000X
FL207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL259314900Medicaid
FLDA3883OtherRAILROAD MEDICARE
FL45233OtherBLUE CROSS BLUE SHIELD
FL45233OtherBLUE CROSS BLUE SHIELD
FL=========OtherTRICARE