Provider Demographics
NPI:1700121464
Name:EAST LAKE MEDICAL, LLC
Entity Type:Organization
Organization Name:EAST LAKE MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:E
Authorized Official - Last Name:LOZANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-482-7301
Mailing Address - Street 1:841 KUHN DR STE 200
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91914-4523
Mailing Address - Country:US
Mailing Address - Phone:619-482-7301
Mailing Address - Fax:619-482-6950
Practice Address - Street 1:841 KUHN DR STE 200
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91914-4523
Practice Address - Country:US
Practice Address - Phone:619-482-7301
Practice Address - Fax:619-482-6950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-06
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48551207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A485510Medicaid
E52093Medicare UPIN
WA48551AMedicare PIN