Provider Demographics
NPI:1639923675
Name:LAKE FAMILY MEDICAL PRACTICE PC
Entity Type:Organization
Organization Name:LAKE FAMILY MEDICAL PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:TUFANO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:631-981-1333
Mailing Address - Street 1:201 PORTION RD STE A
Mailing Address - Street 2:
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-4172
Mailing Address - Country:US
Mailing Address - Phone:631-981-1333
Mailing Address - Fax:631-981-2326
Practice Address - Street 1:201 PORTION RD STE A
Practice Address - Street 2:
Practice Address - City:LAKE RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-4172
Practice Address - Country:US
Practice Address - Phone:631-981-1333
Practice Address - Fax:631-981-2326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-16
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty