Provider Demographics
NPI:1972801827
Name:LAKE GASTROENTEROLOGY ASSOCIATES LLC
Entity Type:Organization
Organization Name:LAKE GASTROENTEROLOGY ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SOUNDARAPANDIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BASKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-636-3652
Mailing Address - Street 1:PO BOX 1345
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32756-1345
Mailing Address - Country:US
Mailing Address - Phone:352-383-5200
Mailing Address - Fax:352-383-3534
Practice Address - Street 1:1703 MAYO DR
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-4307
Practice Address - Country:US
Practice Address - Phone:352-383-5200
Practice Address - Fax:352-383-3534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-02
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLEU008AMedicare PIN