Basic Information
| Provider Information | |||||||||
| NPI: | 1548526155 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VASCULAR SPECIALISTS OF LAKELAND, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2125 CRYSTAL GROVE DR | ||||||||
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| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338016875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636882334 | ||||||||
| FaxNumber: | 8635771167 | ||||||||
| Practice Location | |||||||||
| Address1: | 2125 CRYSTAL GROVE DR | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338016875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636882334 | ||||||||
| FaxNumber: | 8635771167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2012 | ||||||||
| LastUpdateDate: | 08/12/2013 | ||||||||
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| AuthorizedOfficialLastName: | GOODEMOTE | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8636882334 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHD, RN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.