Healthcare Provider Details

I. General information

NPI: 1265409635
Provider Name (Legal Business Name): LAKES RADIOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2006
Last Update Date: 09/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8395 OSWEGO RD
BALDWINSVILLE NY
13027-6801
US

IV. Provider business mailing address

PO BOX 2004
EAST SYRACUSE NY
13057-4504
US

V. Phone/Fax

Practice location:
  • Phone: 315-857-0094
  • Fax:
Mailing address:
  • Phone: 315-362-5285
  • Fax: 315-445-2936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: IDDO NETANYAHU
Title or Position: PRESIDENT
Credential: MD
Phone: 315-857-0094