Provider Demographics
NPI:1518973973
Name:LAKESIDE PEDIATRICS NORTH
Entity Type:Organization
Organization Name:LAKESIDE PEDIATRICS NORTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:J
Authorized Official - Last Name:CORY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-688-3550
Mailing Address - Street 1:2929 LAKELAND HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-2223
Mailing Address - Country:US
Mailing Address - Phone:863-688-3550
Mailing Address - Fax:863-687-8969
Practice Address - Street 1:2929 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-2223
Practice Address - Country:US
Practice Address - Phone:863-688-3550
Practice Address - Fax:863-687-8969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251933000Medicaid