Healthcare Provider Details

I. General information

NPI: 1790053981
Provider Name (Legal Business Name): LAKES INTERVENTIONAL RADIOLOGY CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2011
Last Update Date: 08/27/2025
Certification Date: 08/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1380 NE MIAMI GARDENS DR STE 240
NORTH MIAMI BEACH FL
33179-4750
US

IV. Provider business mailing address

16855 NE 2ND AVE STE 305
NORTH MIAMI BEACH FL
33162-1744
US

V. Phone/Fax

Practice location:
  • Phone: 305-907-6191
  • Fax: 305-907-6192
Mailing address:
  • Phone: 305-907-6191
  • Fax: 305-907-6192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberOSR807
License Number StateFL

VIII. Authorized Official

Name: DR. MOISES ROIZENTAL
Title or Position: PRESIDENT
Credential:
Phone: 305-907-6191