Provider Demographics
NPI:1881837243
Name:LAKESIDE EYECARE
Entity Type:Organization
Organization Name:LAKESIDE EYECARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:LLOYD
Authorized Official - Last Name:CALDERWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-676-1422
Mailing Address - Street 1:312 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2812
Mailing Address - Country:US
Mailing Address - Phone:208-676-1422
Mailing Address - Fax:208-667-7730
Practice Address - Street 1:312 N 4TH ST
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2812
Practice Address - Country:US
Practice Address - Phone:208-676-1422
Practice Address - Fax:208-667-7730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-15
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100067152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807139300Medicaid
ID6233270001Medicare NSC
ID807139300Medicaid