Provider Demographics
NPI:1982809372
Name:LAKESHORE MEDICAL CLINIC, LTD
Entity type:Organization
Organization Name:LAKESHORE MEDICAL CLINIC, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MASOOD
Authorized Official - Middle Name:
Authorized Official - Last Name:WASIULLAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-744-6589
Mailing Address - Street 1:5818 W CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-2247
Mailing Address - Country:US
Mailing Address - Phone:414-449-2114
Mailing Address - Fax:
Practice Address - Street 1:5818 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-2247
Practice Address - Country:US
Practice Address - Phone:414-449-2114
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0458040002Medicare ID - Type Unspecified