Healthcare Provider Details

I. General information

NPI: 1982809372
Provider Name (Legal Business Name): LAKESHORE MEDICAL CLINIC, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5818 W CAPITOL DR
MILWAUKEE WI
53216-2247
US

IV. Provider business mailing address

5818 W CAPITOL DR
MILWAUKEE WI
53216-2247
US

V. Phone/Fax

Practice location:
  • Phone: 414-449-2114
  • Fax:
Mailing address:
  • Phone: 414-449-2114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MASOOD WASIULLAH
Title or Position: PRESIDENT
Credential: MD
Phone: 414-744-6589