Provider Demographics
NPI:1851489520
Name:LAKESIDE SURGERY, P.A.
Entity Type:Organization
Organization Name:LAKESIDE SURGERY, P.A.
Other - Org Name:LAKESIDE SURGERY, P.A.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SURGEON/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:R
Authorized Official - Last Name:MAKOHON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-722-3290
Mailing Address - Street 1:2850 SHORELINE TRL
Mailing Address - Street 2:PMB 154
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75032-5508
Mailing Address - Country:US
Mailing Address - Phone:972-772-3290
Mailing Address - Fax:469-402-2585
Practice Address - Street 1:3142 HORIZON RD
Practice Address - Street 2:SUITE 206
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-7809
Practice Address - Country:US
Practice Address - Phone:972-722-3290
Practice Address - Fax:469-402-2585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6483174400000X
TXJ2983174400000X
TXP6593174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1326097676OtherNPI
TX1952393415OtherNPI
TX1952393415OtherNPI