| East Lake Medical Clinic | |
|
4737 Old Canoe Creek Rd Saint Cloud FL 34769-1400 | |
| (407) 705-3222 | |
| Not Available |
| Full Name | East Lake Medical Clinic |
|---|---|
| Speciality | Clinic/Center |
| Location | 4737 Old Canoe Creek Rd, Saint Cloud, Florida |
| Authorized Official Name and Position | Dustin Ly (PRESIDENT) |
| Authorized Official Contact | 4077053222 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| East Lake Medical Clinic 4737 Old Canoe Creek Rd Saint Cloud FL 34769-1400 Ph: () - | East Lake Medical Clinic 4737 Old Canoe Creek Rd Saint Cloud FL 34769-1400 Ph: (407) 705-3222 |
| NPI Number | 1790124741 |
|---|---|
| Provider Enumeration Date | 06/21/2013 |
| Last Update Date | 06/21/2013 |
| Medicare PECOS PAC ID | 8325282924 |
|---|---|
| Medicare Enrollment ID | O20130923000074 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1790124741 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QP2300X | Clinic/center - Primary Care | ME114777 (Florida) | Primary |
| Provider Name | Dustin N Ly |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1710195268 PECOS PAC ID: 4587808183 Enrollment ID: I20130923000148 |
| Provider Name | Amanda Parveena Nath |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1306528070 PECOS PAC ID: 5294186342 Enrollment ID: I20240112002421 |
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