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General NPI Number Information
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NPI Number | 1699940635
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Entity Type | Organization
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Legal Business Name | SOUTH LAKE MEDICINE P A
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Dates
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Enumeration Date | 04/29/2008
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Last Update Date | 07/12/2010
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Provider Practice Location Address
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Address Line | 3190 CITRUS TOWER BLVD
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City | CLERMONT
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State | FL
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Zip | 34711-6802
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Country | US
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Telephone | 352-242-2282
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Fax | 352-242-2886
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Provider Business Mailing Address
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Address Line | 3190 CITRUS TOWER BLVD
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City | CLERMONT
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State | FL
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Zip | 34711-6802
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Country | US
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Telephone | 352-242-2282
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Fax | 352-242-2886
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Authorized Official
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Title or Position | OWNER
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Name | DR. HANXIAN HUANG
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Credential | M.D., PH.D.
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Telephone | 352-242-2282
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QA0505X
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Taxonomy Name | Adult Medicine Physician
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License Number | ME83976
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License Number State | FL
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