1780773317 NPI number — LAKE FOOT AND ANKLE PA

Table of content: (NPI 1780773317)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780773317 NPI number — LAKE FOOT AND ANKLE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE FOOT AND ANKLE PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780773317
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/13/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1330 CITIZENS BLVD
Provider Second Line Business Mailing Address:
SUITE 301
Provider Business Mailing Address City Name:
LEESBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34748-3959
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-728-1252
Provider Business Mailing Address Fax Number:
352-728-0079

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1330 CITIZENS BLVD
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
LEESBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34748-3959
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-728-1252
Provider Business Practice Location Address Fax Number:
352-728-0079
Provider Enumeration Date:
10/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WEBER
Authorized Official First Name:
KARSTEN
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
352-728-1252

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  PO 3114 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DG4530 . This is a "RAILROAD MEDICARE GROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P00436246 . This is a "RAILROAD MEDICARE PTAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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