Provider Demographics
NPI:1184884777
Name:LAKESIDE FOOT CLINIC, PC
Entity type:Organization
Organization Name:LAKESIDE FOOT CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:SHIMKO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:704-892-3399
Mailing Address - Street 1:19453 W CATAWBA AVE STE A
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-4022
Mailing Address - Country:US
Mailing Address - Phone:704-892-3399
Mailing Address - Fax:704-892-5113
Practice Address - Street 1:19453 W CATAWBA AVE STE A
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-4022
Practice Address - Country:US
Practice Address - Phone:704-892-3399
Practice Address - Fax:704-892-5113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-17
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC270213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890816HMedicaid
NC0816HOtherBLUE CROSS BLUE SHIELD
NC5384190001Medicare NSC
NC0816HOtherBLUE CROSS BLUE SHIELD
NCT97095Medicare UPIN