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General NPI Number Information
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NPI Number | 1851489520
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Entity Type | Organization
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Legal Business Name | LAKESIDE SURGERY, P.A.
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Dates
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Enumeration Date | 10/10/2006
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Last Update Date | 06/07/2013
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Provider Practice Location Address
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Address Line | 3142 HORIZON RD SUITE 206
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City | ROCKWALL
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State | TX
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Zip | 75032-7809
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Country | US
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Telephone | 972-722-3290
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Fax | 469-402-2585
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Provider Business Mailing Address
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Address Line | 2850 SHORELINE TRL PMB 154
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City | ROCKWALL
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State | TX
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Zip | 75032-5508
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Country | US
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Telephone | 972-772-3290
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Fax | 469-402-2585
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Authorized Official
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Title or Position | SURGEON/OWNER
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Name | KATHERINE R MAKOHON
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Credential | MD
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Telephone | 972-722-3290
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | J2983
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | P6593
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License Number State | TX
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Taxonomy #3
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | K6483
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License Number State | TX
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