Healthcare Provider Details

I. General information

NPI: 1093747560
Provider Name (Legal Business Name): LAKE CANCER MEDICAL CENTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 08/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

732 NORTH THIRD STREET
LEESBURG FL
34748
US

IV. Provider business mailing address

732 NORTH THIRD STREET
LEESBURG FL
34748
US

V. Phone/Fax

Practice location:
  • Phone: 352-728-2532
  • Fax: 352-728-3004
Mailing address:
  • Phone: 352-728-2532
  • Fax: 352-728-3004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME81152
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberME24875
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberME80262
License Number StateFL

VIII. Authorized Official

Name: MRS. LOURDES M MATHEW
Title or Position: MD
Credential: MD
Phone: 352-728-2532