Provider Demographics
NPI:1619973054
Name:LAKESIDE DERMATOLOGY , PA
Entity type:Organization
Organization Name:LAKESIDE DERMATOLOGY , PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:J
Authorized Official - Last Name:ASTLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-892-4878
Mailing Address - Street 1:19900 W CATAWBA AVE
Mailing Address - Street 2:STE B
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-4032
Mailing Address - Country:US
Mailing Address - Phone:704-892-4878
Mailing Address - Fax:704-892-7453
Practice Address - Street 1:19900 W CATAWBA AVE
Practice Address - Street 2:SUITE B
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-4032
Practice Address - Country:US
Practice Address - Phone:704-892-4878
Practice Address - Fax:704-892-7453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9400198207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC01056OtherBCBS
CA0767OtherRAILROAD MEDICARE
E82914OtherUPIN
2316408Medicare ID - Type Unspecified
E38564Medicare UPIN