Healthcare Provider Details

I. General information

NPI: 1104087774
Provider Name (Legal Business Name): LAKESIDE MEDICAL ASSOCIATES A MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2008
Last Update Date: 05/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4955 VAN NUYS BLVD SUITE 308
SHERMAN OAKS CA
91403-1811
US

IV. Provider business mailing address

777 FLOWER STREET SUITE A
GLENDALE CA
91201-3000
US

V. Phone/Fax

Practice location:
  • Phone: 818-907-5088
  • Fax: 818-907-5891
Mailing address:
  • Phone: 818-637-2000
  • Fax: 818-242-8761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KERRY E WEINER
Title or Position: PRESIDENT
Credential: MD
Phone: 818-637-2000