Provider Demographics
NPI:1497754121
Name:SOUTH LAKE OBSTETRICS & GYNECOLOGY, LLC
Entity Type:Organization
Organization Name:SOUTH LAKE OBSTETRICS & GYNECOLOGY, LLC
Other - Org Name:SOUTH LAKE OB/GYN AND ADVANCED SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:STEPHAN
Authorized Official - Last Name:CASAVANT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:321-436-8371
Mailing Address - Street 1:1900 DON WICKHAM DR STE 120
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-1980
Mailing Address - Country:US
Mailing Address - Phone:352-241-7050
Mailing Address - Fax:352-241-7035
Practice Address - Street 1:1900 DON WICKHAM DR STE 120
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-1980
Practice Address - Country:US
Practice Address - Phone:352-241-7050
Practice Address - Fax:352-241-7035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-15
Last Update Date:2024-03-13
Deactivation Date:2005-07-18
Deactivation Code:
Reactivation Date:2008-01-28
Provider Licenses
StateLicense IDTaxonomies
FLOS8678207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264093700Medicaid
FLH54064Medicare UPIN
FLK3688Medicare PIN