Provider Demographics
NPI:1366855967
Name:LAKE CANCER & HEMATOLOGY PA
Entity Type:Organization
Organization Name:LAKE CANCER & HEMATOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LOURDES
Authorized Official - Middle Name:M
Authorized Official - Last Name:MATHEW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-728-2532
Mailing Address - Street 1:732 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-4442
Mailing Address - Country:US
Mailing Address - Phone:352-728-2532
Mailing Address - Fax:352-728-3004
Practice Address - Street 1:732 N 3RD ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-4442
Practice Address - Country:US
Practice Address - Phone:352-728-2532
Practice Address - Fax:352-728-3004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-11
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME24875174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL056387100Medicaid
FL056387100Medicaid