Provider Demographics
NPI:1558423822
Name:LAKESIDE MEDICAL GROUP-DR. RAJ CHAWLA P.C.
Entity Type:Organization
Organization Name:LAKESIDE MEDICAL GROUP-DR. RAJ CHAWLA P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAJ
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAWLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-809-6494
Mailing Address - Street 1:14300 GALLANT FOX LN STE 205
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-4033
Mailing Address - Country:US
Mailing Address - Phone:301-809-6494
Mailing Address - Fax:301-809-6497
Practice Address - Street 1:14300 GALLANT FOX LN STE 210
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-4033
Practice Address - Country:US
Practice Address - Phone:301-809-5556
Practice Address - Fax:301-809-5510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD407439400Medicaid
MDG01985Medicare PIN