Basic Information
| Provider Information | |||||||||
| NPI: | 1255403762 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKELAND DERMATOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 202 LAKE MIRIAM DR STE S1 | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338132188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636472333 | ||||||||
| FaxNumber: | 8633931995 | ||||||||
| Practice Location | |||||||||
| Address1: | 202 LAKE MIRIAM DR STE S1 | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338132188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636472333 | ||||||||
| FaxNumber: | 8633931995 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2006 | ||||||||
| LastUpdateDate: | 11/04/2010 | ||||||||
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| AuthorizedOfficialLastName: | MURRAY | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 8636472333 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.