Provider Demographics
NPI:1609055276
Name:LAKESIDE NEUROLOGY LLC
Entity Type:Organization
Organization Name:LAKESIDE NEUROLOGY LLC
Other - Org Name:TIN T. WIN, M.D.
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIN
Authorized Official - Middle Name:T
Authorized Official - Last Name:WIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-680-8282
Mailing Address - Street 1:PO BOX 1440
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86405-1440
Mailing Address - Country:US
Mailing Address - Phone:928-680-8282
Mailing Address - Fax:928-680-8288
Practice Address - Street 1:2180 MCCULLOCH BLVD N
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6879
Practice Address - Country:US
Practice Address - Phone:928-680-8282
Practice Address - Fax:928-680-8288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28212174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1659357929OtherGROUP NPI NUMBER