Basic Information
| Provider Information | |||||||||
| NPI: | 1437346657 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKE DERMATOLOGY MEDICAL ASSOC INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JAMES R KAHN MD | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5144 HILL RD E | ||||||||
| Address2: | |||||||||
| City: | LAKEPORT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954536300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072638955 | ||||||||
| FaxNumber: | 7072638340 | ||||||||
| Practice Location | |||||||||
| Address1: | 5144 HILL RD E | ||||||||
| Address2: | |||||||||
| City: | LAKEPORT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954536300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072638955 | ||||||||
| FaxNumber: | 7072638340 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2007 | ||||||||
| LastUpdateDate: | 10/02/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KAHN | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | ROGER | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7072638955 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | G058941 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | ZZZ05922Z | 01 | CA | BLUE SHIELD | OTHER | 00G589410 | 05 | CA | MEDICAID |