Provider Demographics
NPI:1992269351
Name:SOUTH LAKE ARTHRITIS AND RHEUMATOLOGY, LLC
Entity type:Organization
Organization Name:SOUTH LAKE ARTHRITIS AND RHEUMATOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:USMAN
Authorized Official - Middle Name:TANVEER
Authorized Official - Last Name:MALIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-607-9564
Mailing Address - Street 1:1259 LATTIMORE DR
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-9034
Mailing Address - Country:US
Mailing Address - Phone:612-607-9564
Mailing Address - Fax:
Practice Address - Street 1:1745 E HWY 50
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-5037
Practice Address - Country:US
Practice Address - Phone:863-606-8714
Practice Address - Fax:863-583-0470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9260700Medicaid