Basic Information
Provider Information | |||||||||
NPI: | 1689654766 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LAKOMY | ||||||||
FirstName: | DALE | ||||||||
MiddleName: | G | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2234 COLONIAL BLVD | ||||||||
Address2: | ATTN: PAYER CONTRACTING & RELATIONS | ||||||||
City: | FORT MYERS | ||||||||
State: | FL | ||||||||
PostalCode: | 339071412 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2399317342 | ||||||||
FaxNumber: | 2399317385 | ||||||||
Practice Location | |||||||||
Address1: | 3663 BEE RIDGE RD | ||||||||
Address2: |   | ||||||||
City: | SARASOTA | ||||||||
State: | FL | ||||||||
PostalCode: | 34233 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9419248700 | ||||||||
FaxNumber: | 9419242320 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/17/2006 | ||||||||
LastUpdateDate: | 03/11/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0203X | ME48835 | FL | N |   | Allopathic & Osteopathic Physicians | Radiology | Therapeutic Radiology | 2085R0001X | ME48835 | FL | Y |   | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
ID | Type | State | Issuer | Description | P513268 | 01 | FL | OPTIMUM | OTHER | 103548 | 01 | FL | AVMED | OTHER | P01257632 | 01 | FL | RAILROAD MCR | OTHER | 1989396 | 01 | FL | CIGNA | OTHER | 37561 | 01 | FL | BCBS OF FL | OTHER | 4018949 | 01 | FL | AETNA | OTHER | P00355694 | 01 |   | R.R.MEDICARE | OTHER | 268344000 | 05 | FL |   | MEDICAID | P102620 | 01 | FL | FREEDOM HEALTH | OTHER |