Provider Demographics
NPI:1902977937
Name:LAKE SHORE DERMATOLOGY, LTD.
Entity Type:Organization
Organization Name:LAKE SHORE DERMATOLOGY, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KAVITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GANDHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-680-7100
Mailing Address - Street 1:351 S. GREENLEAF
Mailing Address - Street 2:SUITE E
Mailing Address - City:PARK CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60085
Mailing Address - Country:US
Mailing Address - Phone:847-680-7100
Mailing Address - Fax:847-406-3345
Practice Address - Street 1:351 S. GREENLEAF
Practice Address - Street 2:SUITE E
Practice Address - City:PARK CITY
Practice Address - State:IL
Practice Address - Zip Code:60085
Practice Address - Country:US
Practice Address - Phone:847-680-7100
Practice Address - Fax:847-406-3345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL336067198207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH74580Medicare UPIN
IL212202Medicare ID - Type Unspecified