Provider Demographics
NPI:1679732689
Name:LAKESIDE FAMILY MEDICINE, P.A.
Entity Type:Organization
Organization Name:LAKESIDE FAMILY MEDICINE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF LAKESIDE FAMILY MEDICI
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:352-589-5900
Mailing Address - Street 1:4685 N HIGHWAY 19A
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-2039
Mailing Address - Country:US
Mailing Address - Phone:352-589-5900
Mailing Address - Fax:352-589-5904
Practice Address - Street 1:4685 N HIGHWAY 19A
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-2039
Practice Address - Country:US
Practice Address - Phone:352-589-5900
Practice Address - Fax:352-589-5904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-04
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care