Provider Demographics
NPI:1568451888
Name:LAKE COUNTY PRIMARY MEDICAL CARE LLC
Entity Type:Organization
Organization Name:LAKE COUNTY PRIMARY MEDICAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUJATHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BASKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-357-0880
Mailing Address - Street 1:33 N CENTER ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-3580
Mailing Address - Country:US
Mailing Address - Phone:352-357-0880
Mailing Address - Fax:352-357-0334
Practice Address - Street 1:33 N CENTER ST
Practice Address - Street 2:SUITE A
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-3580
Practice Address - Country:US
Practice Address - Phone:352-357-0880
Practice Address - Fax:352-357-0334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-19
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL274014100Medicaid
FLK9024Medicare PIN