Provider Demographics
NPI:1811902604
Name:LAKE UROLOGY CLINIC
Entity type:Organization
Organization Name:LAKE UROLOGY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:FOUAD
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHAMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-787-4567
Mailing Address - Street 1:616 N PALMETTO ST
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-4417
Mailing Address - Country:US
Mailing Address - Phone:352-787-4567
Mailing Address - Fax:352-787-0370
Practice Address - Street 1:616 N PALMETTO ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-4417
Practice Address - Country:US
Practice Address - Phone:352-787-4567
Practice Address - Fax:352-787-0370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty