Provider Demographics
NPI:1376210500
Name:LAKESIDE MEDICAL PLLC
Entity Type:Organization
Organization Name:LAKESIDE MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GAYLON
Authorized Official - Middle Name:E
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:928-367-6828
Mailing Address - Street 1:300 W WHITE MOUNTAIN BLVD #C
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-7014
Mailing Address - Country:US
Mailing Address - Phone:928-367-6828
Mailing Address - Fax:928-367-4037
Practice Address - Street 1:300 W WHITE MOUNTAIN BLVD #C
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-7014
Practice Address - Country:US
Practice Address - Phone:928-367-6828
Practice Address - Fax:928-367-4037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-25
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ368333Medicaid