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General NPI Number Information
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NPI Number | 1184884777
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Entity Type | Organization
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Legal Business Name | LAKESIDE FOOT CLINIC, PC
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Dates
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Enumeration Date | 06/17/2008
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Last Update Date | 03/23/2015
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Provider Practice Location Address
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Address Line | 19453 W CATAWBA AVE STE A
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City | CORNELIUS
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State | NC
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Zip | 28031-4022
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Country | US
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Telephone | 704-892-3399
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Fax | 704-892-5113
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Provider Business Mailing Address
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Address Line | 19453 W CATAWBA AVE STE A
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City | CORNELIUS
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State | NC
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Zip | 28031-4022
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Country | US
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Telephone | 704-892-3399
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Fax | 704-892-5113
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Authorized Official
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Title or Position | SOLE PROPRIETOR
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Name | DR. JOHN MICHAEL SHIMKO
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Credential | DPM
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Telephone | 704-892-3399
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | 270
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License Number State | NC
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