MEDICARE: LAKESIDE MEDICAL ASSOCIATES, P. A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	F2507	TX

General Provider Information

NPI Number	:	1184846776
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKESIDE MEDICAL ASSOCIATES, P. A.

Provider Business Mailing Address
First Line	:	6053 MAIN ST
Second Line	:	SUITE 130
City	:	THE COLONY
State	:	TX
Zip	:	75056-4706
Country	:	US
Telephone Number	:	972-625-7000
Fax Number	:	972-625-8787

Provider Business Practice Location Address
First Line	:	6053 MAIN ST
Second Line	:	SUITE 130
City	:	THE COLONY
State	:	TX
Zip	:	75056-4706
Country	:	US
Telephone Number	:	972-625-7000
Fax Number	:	972-625-8787

Authorized Official
Title or Position	:	PRESIDENT
Name	:	GARY VOLLENWEIDER
Credential	:
Telephone Number	:	972-625-7000

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	01/20/2017

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