Provider Demographics
NPI:1629091996
Name:LAKE ENT & FPS, PA
Entity Type:Organization
Organization Name:LAKE ENT & FPS, PA
Other - Org Name:LAKE EAR, NOSE THROAT AND FACIAL PLASTIC SURGERY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:C
Authorized Official - Last Name:MILSTEAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-728-2404
Mailing Address - Street 1:601 E DIXIE AVE
Mailing Address - Street 2:PLAZA 901
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-5953
Mailing Address - Country:US
Mailing Address - Phone:352-728-2404
Mailing Address - Fax:352-787-7401
Practice Address - Street 1:601 E DIXIE AVE
Practice Address - Street 2:PLAZA 901
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5953
Practice Address - Country:US
Practice Address - Phone:352-728-2404
Practice Address - Fax:352-787-7401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00941Medicare PIN