Provider Demographics
NPI:1881631778
Name:LAKE MARY FAMILY MEDICINE, INC.
Entity Type:Organization
Organization Name:LAKE MARY FAMILY MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SUREE
Authorized Official - Middle Name:
Authorized Official - Last Name:VYAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-830-1975
Mailing Address - Street 1:320 W SABAL PALM PL
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-3639
Mailing Address - Country:US
Mailing Address - Phone:407-260-1137
Mailing Address - Fax:407-332-7893
Practice Address - Street 1:109 TIMBERLACHEN CIR
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3395
Practice Address - Country:US
Practice Address - Phone:407-333-9877
Practice Address - Fax:407-333-9881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty