Provider Demographics
NPI:1356553093
Name:LAKEVIEW PEDIATRICS
Entity type:Organization
Organization Name:LAKEVIEW PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MALGORZATA
Authorized Official - Middle Name:
Authorized Official - Last Name:KORTOWSKA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-340-6225
Mailing Address - Street 1:LAKEVIEW PEDIATRICS
Mailing Address - Street 2:266 LAKEVIEW AVE
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07011
Mailing Address - Country:US
Mailing Address - Phone:973-340-6225
Mailing Address - Fax:973-340-0665
Practice Address - Street 1:LAKEVIEW PEDIATRICS
Practice Address - Street 2:266 LAKEVIEW AVE
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011
Practice Address - Country:US
Practice Address - Phone:973-340-6225
Practice Address - Fax:973-340-0665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA065909208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7560401Medicaid
H63044Medicare UPIN