Healthcare Provider Details

I. General information

NPI: 1710937727
Provider Name (Legal Business Name): LAKES RADIOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 02/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 CANISTEO ST RADIOLOGY
HORNELL NY
14843-2104
US

IV. Provider business mailing address

7 ERIE AVE RADIOLOGY
HORNELL NY
14843-1909
US

V. Phone/Fax

Practice location:
  • Phone: 607-324-8255
  • Fax: 607-324-8774
Mailing address:
  • Phone: 607-324-8255
  • Fax: 607-324-8774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number167192
License Number StateNY

VIII. Authorized Official

Name: DR. IDDO NETANYAHU
Title or Position: CEO
Credential: MD
Phone: 607-324-8255