Healthcare Provider Details

I. General information

NPI: 1689869760
Provider Name (Legal Business Name): LAKESIDE MEDICAL ASSOCIATES, A MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 05/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12660 RIVERSIDE DR SUITE 225
N HOLLYWOOD CA
91607-3429
US

IV. Provider business mailing address

777 FLOWER ST STE A
GLENDALE CA
91201-3000
US

V. Phone/Fax

Practice location:
  • Phone: 818-755-0265
  • Fax: 818-753-9074
Mailing address:
  • Phone: 818-637-2000
  • Fax: 818-242-8761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: KERRY E. WEINER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 818-637-2000