Healthcare Provider Details

I. General information

NPI: 1962418343
Provider Name (Legal Business Name): LAKESIDE PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 05/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5950 S FLORIDA AVE
LAKELAND FL
33813-2532
US

IV. Provider business mailing address

5950 S FLORIDA AVE
LAKELAND FL
33813-2532
US

V. Phone/Fax

Practice location:
  • Phone: 863-688-3550
  • Fax: 863-687-8969
Mailing address:
  • Phone: 863-688-3550
  • Fax: 863-687-8969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MATTHEW J CORY
Title or Position: PARTNER
Credential: MD
Phone: 863-688-3550