Provider Demographics
NPI:1598323909
Name:LAKESIDE FOOT AND LEG CARE PLLC
Entity Type:Organization
Organization Name:LAKESIDE FOOT AND LEG CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SIRAJ
Authorized Official - Middle Name:
Authorized Official - Last Name:PANCHBHAIYA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:248-739-1379
Mailing Address - Street 1:14322 GRANDVIEW DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-3447
Mailing Address - Country:US
Mailing Address - Phone:248-739-1379
Mailing Address - Fax:
Practice Address - Street 1:14322 GRANDVIEW DR
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-3447
Practice Address - Country:US
Practice Address - Phone:248-739-1379
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-31
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty