Provider Demographics
NPI:1831682814
Name:LAKE ALLERGY, ASTHMA AND IMMUNOLOGY, PA
Entity type:Organization
Organization Name:LAKE ALLERGY, ASTHMA AND IMMUNOLOGY, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:J
Authorized Official - Last Name:COOKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-609-0140
Mailing Address - Street 1:1822 SALK AVE
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-4300
Mailing Address - Country:US
Mailing Address - Phone:954-609-0140
Mailing Address - Fax:888-220-7924
Practice Address - Street 1:1822 SALK AVE
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-4300
Practice Address - Country:US
Practice Address - Phone:525-531-7173
Practice Address - Fax:888-220-7924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-13
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME118840207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8G0U6OtherBCBS
FL207K00000XMedicaid