Provider Demographics
NPI:1942367370
Name:LAKE PEDIATRICS P. A.
Entity Type:Organization
Organization Name:LAKE PEDIATRICS P. A.
Other - Org Name:LAKE PEDIATRICS, P.A.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:NETTLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:523-638-4997
Mailing Address - Street 1:4880 N HWY 19 A
Mailing Address - Street 2:
Mailing Address - City:MT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-2018
Mailing Address - Country:US
Mailing Address - Phone:352-589-8111
Mailing Address - Fax:352-589-8495
Practice Address - Street 1:4880 N HWY 19 A
Practice Address - Street 2:
Practice Address - City:MT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-2018
Practice Address - Country:US
Practice Address - Phone:352-589-8111
Practice Address - Fax:352-589-8111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL660103100Medicaid