Provider Demographics
NPI:1679828842
Name:GUY, LAKEDRIAN (IDMT)
Entity Type:Individual
Prefix:MR
First Name:LAKEDRIAN
Middle Name:
Last Name:GUY
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 COURTHOUSE RD APT 1521
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-4298
Mailing Address - Country:US
Mailing Address - Phone:850-450-7044
Mailing Address - Fax:
Practice Address - Street 1:980 COURTHOUSE RD APT 1521
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-4298
Practice Address - Country:US
Practice Address - Phone:850-450-7044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-13
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians