Provider Demographics
NPI:1699076901
Name:SOUTH LAKE PEDIATRICS, P.A.
Entity type:Organization
Organization Name:SOUTH LAKE PEDIATRICS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ADINARAYANAMURTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:NALLAMSHETTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-242-1500
Mailing Address - Street 1:3155 CITRUS TOWER BLVD
Mailing Address - Street 2:BLDG.# 1
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-6803
Mailing Address - Country:US
Mailing Address - Phone:352-242-1500
Mailing Address - Fax:352-242-0053
Practice Address - Street 1:3155 CITRUS TOWER BLVD
Practice Address - Street 2:BLDG.# 1
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-6803
Practice Address - Country:US
Practice Address - Phone:352-242-1500
Practice Address - Fax:352-242-0053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-03
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME073750208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL260240700Medicaid