Provider Demographics
NPI:1346486032
Name:LAKESIDE INTERNAL MEDICINE ASSOCIATES,LLC
Entity Type:Organization
Organization Name:LAKESIDE INTERNAL MEDICINE ASSOCIATES,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:856-374-5304
Mailing Address - Street 1:1300 LIBERTY PL
Mailing Address - Street 2:
Mailing Address - City:SICKLERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08081-5710
Mailing Address - Country:US
Mailing Address - Phone:856-374-5304
Mailing Address - Fax:
Practice Address - Street 1:1300 LIBERTY PL
Practice Address - Street 2:
Practice Address - City:SICKLERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08081-5710
Practice Address - Country:US
Practice Address - Phone:856-374-5304
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-30
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB47569207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty