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General NPI Number Information
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NPI Number | 1376210500
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Entity Type | Organization
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Legal Business Name | LAKESIDE MEDICAL PLLC
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Dates
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Enumeration Date | 08/25/2021
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Last Update Date | 03/16/2022
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Provider Practice Location Address
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Address Line | 300 W WHITE MOUNTAIN BLVD #C
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City | LAKESIDE
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State | AZ
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Zip | 85929-7014
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Country | US
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Telephone | 928-367-6828
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Fax | 928-367-4037
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Provider Business Mailing Address
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Address Line | 300 W WHITE MOUNTAIN BLVD #C
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City | LAKESIDE
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State | AZ
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Zip | 85929-7014
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Country | US
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Telephone | 928-367-6828
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Fax | 928-367-4037
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. GAYLON E CRAWFORD
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Credential | D.O.
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Telephone | 928-367-6828
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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