Provider Demographics
NPI:1356149942
Name:CENTRAL LAKES MEDICAL CORPORATION
Entity type:Organization
Organization Name:CENTRAL LAKES MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:L
Authorized Official - Last Name:ATIENO OLONDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:443-470-2698
Mailing Address - Street 1:7923 HONEYGO BLVD
Mailing Address - Street 2:217
Mailing Address - City:NOTTINGHAM
Mailing Address - State:MD
Mailing Address - Zip Code:21236
Mailing Address - Country:US
Mailing Address - Phone:443-470-2698
Mailing Address - Fax:883-973-3543
Practice Address - Street 1:7923 HONEYGO BLVD
Practice Address - Street 2:217
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236
Practice Address - Country:US
Practice Address - Phone:443-470-2698
Practice Address - Fax:883-973-3543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-07
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty