Provider Demographics
NPI:1801651328
Name:MEDICAL ASSOCIATES OF LAKE NONA, LLC
Entity type:Organization
Organization Name:MEDICAL ASSOCIATES OF LAKE NONA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:B
Authorized Official - Last Name:DODSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-795-6380
Mailing Address - Street 1:PO BOX 560538
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32956-0538
Mailing Address - Country:US
Mailing Address - Phone:321-795-6380
Mailing Address - Fax:321-208-8717
Practice Address - Street 1:2428 CLEARLAKE RD BLDG K
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-5722
Practice Address - Country:US
Practice Address - Phone:321-795-6380
Practice Address - Fax:321-208-8717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-14
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty