Provider Demographics
NPI:1598843914
Name:LAKE DERMATOLOGY PA
Entity Type:Organization
Organization Name:LAKE DERMATOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GENEVIEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-365-6650
Mailing Address - Street 1:1132 E NORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-5350
Mailing Address - Country:US
Mailing Address - Phone:352-365-6650
Mailing Address - Fax:352-365-0932
Practice Address - Street 1:1132 E NORTH BLVD
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5350
Practice Address - Country:US
Practice Address - Phone:352-365-6650
Practice Address - Fax:352-365-0932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME64096261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL40654Medicare ID - Type UnspecifiedGROUP NUMBER