Provider Demographics
NPI:1205240686
Name:LAKESHORE MEDICAL CLINIC
Entity type:Organization
Organization Name:LAKESHORE MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:LAVORA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:414-768-5430
Mailing Address - Street 1:3305 S 20TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-4940
Mailing Address - Country:US
Mailing Address - Phone:414-645-1808
Mailing Address - Fax:
Practice Address - Street 1:3305 S 20TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4940
Practice Address - Country:US
Practice Address - Phone:414-645-1808
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-13
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI178111-30363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty