Provider Demographics
NPI:1437346657
Name:LAKE DERMATOLOGY MEDICAL ASSOC INC
Entity Type:Organization
Organization Name:LAKE DERMATOLOGY MEDICAL ASSOC INC
Other - Org Name:JAMES R KAHN MD
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ROGER
Authorized Official - Last Name:KAHN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-263-8955
Mailing Address - Street 1:5144 HILL RD E
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-6300
Mailing Address - Country:US
Mailing Address - Phone:707-263-8955
Mailing Address - Fax:707-263-8340
Practice Address - Street 1:5144 HILL RD E
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-6300
Practice Address - Country:US
Practice Address - Phone:707-263-8955
Practice Address - Fax:707-263-8340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG058941207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ05922ZOtherBLUE SHIELD
CA00G589410Medicaid
CAA93525Medicare UPIN
CA00G589410Medicaid