Provider Demographics
NPI:1518923408
Name:LAKE COUNTY ONCOLOGY AND HEMATOLOGY
Entity Type:Organization
Organization Name:LAKE COUNTY ONCOLOGY AND HEMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROY
Authorized Official - Middle Name:M
Authorized Official - Last Name:AMBINDER
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:386-774-5211
Mailing Address - Street 1:PO BOX 741240
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32774-1240
Mailing Address - Country:US
Mailing Address - Phone:386-774-5211
Mailing Address - Fax:386-774-5251
Practice Address - Street 1:4100 WATERMAN WAY
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-5270
Practice Address - Country:US
Practice Address - Phone:386-774-5211
Practice Address - Fax:386-774-5251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-21
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL06000041448207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL258998200Medicaid
FL72375Medicare ID - Type Unspecified