Healthcare Provider Details

I. General information

NPI: 1659826519
Provider Name (Legal Business Name): LAKEWOOD IOM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2016
Last Update Date: 08/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7324 GASTON AVE STE 124
DALLAS TX
75214-6190
US

IV. Provider business mailing address

7324 GASTON AVE STE 124
DALLAS TX
75214-6190
US

V. Phone/Fax

Practice location:
  • Phone: 214-269-3875
  • Fax: 903-328-6568
Mailing address:
  • Phone: 214-269-3875
  • Fax: 903-328-6568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204R00000X
TaxonomyElectrodiagnostic Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: PAUL SCHULMAN
Title or Position: MANAGER
Credential:
Phone: 214-269-3875